'RJ'+s 


As3 


ttx  tlxe  mtn  of  ^cxo  WioxU 
College  of  ||Dl)igs!ician0  atiD  burgeons 


li^eference   Eibrarp 


BY  HENRY  ASHBY,   IVl.D.,  F.R.C.P. 

Sixth  Edition.      With  141  Illustj-ations.     Fcp.  8vo.  price  $1.50. 

NOTES    ON    PHYSIOLOGY   FOR   THE    USE 
OF    STUDENTS. 

Second  Edition.      With  25  Illustrations.     Crozun  8zw.  $1.23. 

HEALTH    IN    THE    NURSERY. 


BY  G.  A.  WRIGHT,   F.R.C.S. 

With  4S  Original  Woodcuts,  Etc. 

HIP    DISEASE    IN    CHILDHOOD. 


\_Out  of  print. 


LONGMANS,    GREEN,    &   CO., 

London,  New  York,  and  Bombay. 


THE 


DISEASES   OF   CHILDREN 


MEDICAL    AND    SURGICAL 


BY 

HENRY  ASHBY,  M.D.Lond,  F.R.C.P. 

PHYSICIAN   TO   THE    GENERAL    HOSPITAL   FOR   SICK    CHILDREN,    MANCHESTER^ 

LECTURER    AND    EXAMINER    IN   DISEASES   OF   CHILDREN    IN   THE    VICTORIA   pNIVERSITY 

FORMERLY    LECTURER   ON    PHYSIOLOGY   IN   THE    OWENS   COLLEGE 

AND    IN   THE   LIVERPOOL   SCHOOL   OF   MEDICINE 

AND 

G.  A.  WRIGHT,  B.A.,  M.B.Oxon.,  F.R.C.S.Eng. 

ASSISTANT   SURGEON   TO   THE    MANCHESTER    ROYAL    INFIRMARY 

AND   SURGEON   TO   THE   CHILDREN'S    HOSPITAL 

LECTURER   ON    PRACTICAL   SURGERY    IN   THE    OWENS   COLLEGE 

FORMERLY    EXAMINER    IN    SURGERY    IN  THE    UNIVERSITY   OF   OXFORD 

CORRESPONDING    MEMBER    OF   THE    AMERICAN    ORTHOPEDIC   ASSOCIATION 


FOURTH    EDITION 

EDITED    FOR    AMERICAN    STUDENTS 

BY 

WILLIAM  PERRY  NORTHRUP,  A.M.,  M.D. 

PROFESSOR   OF    PEDIATRICS,    THE    UNIVERSITY   AND    BELLEVUE    HOSPITAL    MEDICAL   COLLEGE 

ATTENDING    PHYSICIAN    NEW   YORK    FOUNDLING,    WILLARD    PARKER,    AND    PRESBYTERIAN    HOSPITALS 

CONSULTING    PHYSICIAN   NEW   YORK   INFANT   ASYLUM 

MEMBER    OF    THE    ASSOCIATION    OF   AMERICAN    PHYSICIANS 


LONGMANS,     GREEN,     AND     CO. 

91  AND  93  FIFTH   AVENUE,   NEW  YORK 

LONDON  AND  BOMBAY 

1900 


Copyright,  1893,  by 
LONGMANS,   GREEN,    AND   CO. 

Copyright,  iSqSi  by 
LONGMANS,   GREEN,    AND   CO. 

Copyright,  i8gg,  by 
LONGMANS,    GREEN,   AND   CO. 

All  rights  reserved 


Press  of  J.  J.  Little  &  Co. 
Aster  Place,  New  York 


THE  SURGICAL  PART  OF  THIS   BOOK  I  DEDICATE 


TO  MY  FATHER 


\ 


G.  A.  IVRIGHT 


347502 


NOTE  TO  THE 

AMERICAN    EDITION 


In  preparing  this  edition  for  the  American  Reader  it  has  been 
thought  best  to  leave  the  body  of  the  book  intact.  The  same  disease 
differs  but  little  in  its  course  in  America  and  in  England  ;  it  is  neces- 
sary, therefore,  to  note  only  such  differences  in  theory  and  in  treat- 
ment as  shall  seem  to  bring  the  book  into  accord  with  present 
American  practice.  This  has  been  done  by  means  of  the  Appendix, 
care  being  taken  to  refer  supplementary  matter  to  its  proper  connec- 
tion in  the  main  work  by  page  references,  and  by  additions  to  the 
Index. 

The  Formulae  (page  865)  have  been  entirely  rewritten  to  conform 
to  the  United  States  Pharmacopoeia. 

The  supplementary  additions  to  the  Surgical  portion  of  the  book 
have  been  made  by  Dr.  T.  Halsted  Myers,  Attending  Orthopaedic 
Surgeon  to  St.  Luke's  Hospital,  and  Foundling  Hospital,  New 
York,  whose  contributions  are  also  embodied   in  the  Appendix. 

The  Editor  trusts  that  these  additions  may  still  further  increase 
the  usefulness  among  American  readers  of  this  complete  and  con- 
densed treatise,  which  has  so  quickly  passed  to  its  fourth  edition. 

W.  P.   N. 


PREFACE 


TO 

THE    FOURTH     EDITION 


In  preparing  the  Fourth  Edition  the  whole  of  the  work  has  been 
thoroughly  revised,  and  many  of  the  chapters  have  been  entirely  re- 
written. Considerable  additions  have  been  made  in  the  text,  some 
sixty  pages,  twenty-five  new  photographs,  and  fourteen  plates  having 
been  added. 

We  must  express  our  best  thanks  to  Mr,  A.  Wilson,  F.R.C.S.,  for 
rewriting  the  chapter  on  Ansesthetics,  to  our  colleague  Dr.  H.  R.  Hutton, 
for  the  use  of  some  of  his  clinical  cases,  and  to  Dr.  E.  M.  Brockbank 
for  much  kindly  help  and  for  the  care  and  trouble  he  has  taken  in 
reading  through  the   proof-sheets. 

HENRY   ASHBY, 
G.   A.   WRIGHT. 
Manchester:  September,  1899. 


PREFACE 

TO 

THE    FIRST    EDITION 


The  present  work  is  intended  to  give  to  senior  students  and  junior 
medical  practitioners  a  fairly  complete,  though  necessarily  condensed, 
account  of  the  various  morbid  conditions  peculiar  to,  or  chiefly  found 
during,  infancy  and  childhood.  Those  diseases  which  are  neither  special 
to  children  nor  modified  by  their  occurrence  in  early  life  are  either 
omitted  altogether  or  only  briefly  considered. 

The  book  is  written  from  a  practical  point  of  view,  and  but  little 
pathological  detail  will  be  found  in  it. 

The  basis  of  our  work  is  our  experience  at  the  General  Hospital 
for  Sick  Children,  Manchester,  an  institution  at  which  some  i,zoo 
in-patients  and  some  10,000  out-patients  are  annually  treated.  Our 
observations  have  extended  over  nearly  ten  years,  and  during  the  whole 
of  that  time  we  have  been  collecting  material  both  at  the  Children's 
Hospital  and  at  the  Royal  Infirmary  for  this  purpose. 

The  original  feature  of  this  book  is  that  it  is  written  conjointly  by  a 
physician  and  a  surgeon ;  it  is  hoped  that  it  presents,  therefore,  a  fairly 
complete  account  of  disease  in  children.  Though  we  are  well  aware 
that  the  book  is  not  an  exhaustive  treatise,  we  think  it  will  be  found 
practical,  and  it  is  at  least  based  on  experience  and  is  not  a  mere 
compilation. 

The  illustrations  are  almost  entirely  taken  from  photographs  of 
cases  that  have  been  under  our  own  care ;  where  this  is  not  so,  their 
source  is  acknowledged. 


X  Diseases  of  Children 

We  have  to  tender  our  cordial  thanks  to  our  friends  and  colleagues, 
both  at  the  Children's  Hospital  and  at  the  Royal  Infirmary,  for  their 
help.  Our  thanks  are  also  due  to  successive  generations  of  house 
surgeons  who  have  kept  the  records  of  our  cases. 

To  our  colleague,  Dr.  Hutton,  for  allowing  us  without  stint  the  use 
of  his  cases,  as  well  as  for  much  help  and  advice  in  correcting  our 
proofs,  our  especial  thanks  are  due  ;  also  to  Messrs.  Southam  and 
Collier,  our  colleagues  at  the  Royal  Infirmary  and  the  Children's 
Hospital,  for  their  care  and  kindness  in  proof-reading.  To  Mr.  Wilson 
we  owe  our  chapter  on  Anaesthetics,  which  is  made  especially  valuable 
by  his  large  experience  in  the  administration  of  these  agents  both  at  the 
Children's  Hospital  and  at  the  Royal  Infirmary.  To  Drs.  Humphreys 
and  Massiah,  our  former  colleagues,  we  are  also  indebted  for  the  use 
of  their  notes  of  cases. 

We  must  also  acknowledge  the  help  rendered  to  us  by  Messrs.  Paine 
and  Benger  in  connection  with  the  formulae  for  medicines  and  external 
applications  given  in  this  work. 

We  cannot  take  leave  of  our  work  without  further  acknowledging 
our  indebtedness  to  the  Board  of  Governors  of  the  Children's  Hospital 
for  their  generous  treatment  of  us,  and  especially  for  enabling  iis  to 
publish  our  annual  abstract  of  cases  treated  at  the  Hospital.  We  also 
desire  to  express  our  appreciation  of  the  value  of  the  work  of  our  sisters 
and  nurses  in  making  observations  of  cases,  and  in  the  preparation  of 
temperature  charts. 

To  Messrs.  Longman,  our  publishers,  we  are  much  indebted  for 
their  liberality  in  allowing  us  to  borrow  woodcuts  from  their  published 
works,  and  for  their  help  in  many  ways ;  we  desire  also  to  acknowledge 
the  great  pains  and  skill  shown  by  Mr.  Pearson  in  engraving  our 
photographs. 

HENRY   ASHBY, 
G.    A.    WRIGHT. 
Manchester  :  May  1889. 


CONTENTS 


CHAPTER    I 

thf:  physiology  of  infancy  and  childhood 

The  periods  of  life,  i  ;  intra-uterine  life,  i  ;  infancy,  i  ;  childhood,  2  ;  youth,  2  ; 
respiration,  3  ;  changes  in  the  circulation  after  birth,  4 ;  amount  of  blood  in 
body,  5  ;  pulse,  5  ;  alimentary  canal,  6  ;  urine,  7  ;  temperature,  8  ;  nervous 
system,  8  ;  sight,  9  ;  hearing,  9  ;  taste,  10  ;  psychical  phenomena,  10  ;  sleep,  10  ; 
body  weight,  10  ;  dentition,  12  ;  mortality,  14 

CHAPTER   H 

THE    DISEASES   INCIDENT   TO    BIRTH 

Asphyxia  neonatorum,  17  ;  apoplexia  neonatorum,  19  ;  cephalhoematoma,  21  ;  htema- 
toma  of  the  sterno-mastoid,  24  ;  occipital  htematoma,  25  ;  obstetrical  paralysis, 
25  ;  icterus  neonatorum,  26  ;  hsemorrhagic  diathesis,  28  ;  acute  fatty  degenera- 
tion of  the  newly-born,  29  ;  Winckel's  disease,  29  ;  gastro-intestinal  hpemorrhage, 
30;  hemorrhage  from  the  genital  organs,  30;  diseases  of  the  navel,  31  ;  um- 
bilical polypus,  31;  omphalitis,  32;  gangrene  of  the  navel,  32;  umbilical 
arteritis,  33  ;  umbilical  phlebitis,  34  ;  umbilical  htemorrhage,  34  ;  tetanus 
nascentium,  35  ;  sclerema  neonatorimi,  36  ;  oedema  neonatorum,  37  ;  gonor- 
rhoea! ophthalmia,  37 


CHAPTER   HI 

THE    HYGIENE    AND    DIET    OF    INFANTS   AND    CHILDREN 

New-born  infants,  38  ;  clothing,  39  ;  infant  feeding,  39  ;  wet  nurses,  41  ;  weaning, 
42  ;  artificial  feeding,  44  ;  cow's  milk,  44  ;  woman's  milk,  46  ;  modified  milk, 
48  ;  whey,  50  ;  diluted  milk,  51  ;  barley  water,  &c.,  51  ;  peptonised  milk,  52  ; 
sterilisation,  52  ;  condensed  milk,  53  ;  dried  milk  foods,  54  ;  amount  of  food, 
55  ;  feeding  bottles,  56  ;  diet  from  6  to  12  months,  56  ;  diet  from  12  months 
to  18  months  of  age,  57  ;  after  18  months,  57  ;  the  care  of  immature  and  weakly 
infants,  58  ;  incubators,  59 


xii  Diseases  of  Children 


CHAPTER   IV 

DISEASES   OF   THE    DIGESTIVE   SYSTEM 

Examination  of  the  mouth,  60  ;  dentition,  60 ;  catarrhal  stomatitis,  64  ;  stomatitis 
erythematosa,  64 ;  aphthae,  64  ;  parasitic  stomatitis,  65  ;  ulcerative  stomatitis, 
67  ;  alveolar  abscess,  68  ;  cancrum  oris,  69  ;  acute  tonsillitis,  70 ;  chronic  ton- 
sillitis, 74  ;  tonsillar  calculus,  76  ;  nasal  adenoids,  77  ;  pharyngitis  gangrenosa, 
77  ;  post-pharyngeal  abscess,  78  ;  stricture  of  oesophagus,  79  ;  swallowing  foreign 
bodies,  80  ;  oesophagitis,  Si 


CHAPTER   V 

DISEASES   OF   THE   DIGESTIVE   SYSTEM    [continued) 

Examination  of  the  abdomen,  82  ;  dyspeptic  diseases,  83  ;  flatulence  and  colic,  84 ; 
vomiting,  84  ;  diarrhoea,  86  ;  constipation,  88  ;  acute  gastric  catarrh,  90  ;  acute 
gastro-intestinal  catarrh — zymotic  diarrhoea,  90 ;  acute  ileo-colitis,  99  ;  meat 
poisoning,  10 1 

CHAPTER   VI 

DISEASES   OF   THE    DIGESTIVE   SYSTEM    {continued) 

Chronic  gastro-intestinal  catarrh — gastro-intestinal  atrophy,  103  ;  chronic  diarrhoea, 
105  ;  chronic  vomiting,  105  ;  diet  for  indigestion,  11 1  ;  dilatation  of  stomach,  1 12  ; 
stenosis  of  pylorus,  113  ;  malformations  of  stomach,  113  ;  carcinoma  of  stomach, 
113;  ulcer  of  stomach,  114;  thread  worms,  114;  round  worms,  115;  tape 
worms,  116;  ascites,  116 


CHAPTER   VII 

DISEASES   OF   THE   DIGESTIVE   SYSTEM   {continued) 

Acute  peritonitis,  118;  perityphlitis,  122;  peritoneal  abscesses — intestinal  fistula, 
124  ;  iliac  abscess,  127  ;  chronic  peritonitis,  128  ;  intussusception,  131  ;  chronic 
obstruction  of  the  bowels,  142 

CHAPTER   VIII 

DISEASES   OF   THE   DIGESTIVE   SYSTEM    {continued) 

Tubercular  ulceration  of  the  bowels — mesenteric  disease,  144  ;  congenital  obstruction 
of  the  bowels,  148  ;  imperforate  anus,  150  ;  deformities  of  the  umbilicus,  154  : 
umbilical  hernia,  155;  inguinal  hernia,  156;  prolapsus  recti,  160;  fistula  in 
ano,  163;  piles,  163;  polypus  of  the  rectum,  163 


Contents  xiii 

CHAPTER    IX 

DISEASES    OF   THE    DIC.ESTINE    SYSTEM    {continued  \ 

Hare-lip,  165  ;  cleft  palate,  171  ;  macrostoma,  174;  inacrocheilia,  175;  microstoma, 
175;  tongue-tie,  175:  macroglossia,  176;  ranula,  176;  papilloma  and  condylo- 
mata of  the  tongue,  177  ;  hypertnjphy  and  atrophy  of  the  face,  177  ;  branchial 
fistula',  17S  ;  supernumerary  auricles,  17S 

CHAPTER    X 

DISEASES   OF   THE    LIVER 

C(Migeniial  stricture  of  the  bile-ducts,  182  ;  catarrhal  jaundice,  183  ;  epidemic  jaun- 
dice, 184;  acute  yellow  atrophy  of  the  liver,  184;  cirrhosis  of  the  liver,  186; 
syphilitic  cirrhosis,  188  ;  fatty  liver,  189  ;  tuberculosis  of  liver,  189  ;  hepatic 
abscess,  190;  hydatids,  190;  tumour  of  the  liver,  191 

CHAPTER   XI 

INFANTILE   SCURVY 
Symptoms,    194  ;  treatment,  196 

CHAPTER   XII 

RICKETS 

Dietetic  influeiices,  198;  symptoms  and  course,  200;  fcetal  rickets,  203;  rickety 
deformities,  208  ;  rickety  spine,  210;  coxa  vara,  211  ;  knock  knees,  212  ;  bow- 
legs, 213  ;  late  rickets,  216  ;  lateral  curvature  of  spine,  223  :  antero-posterior 
curvature,  227 

CHAPTER  X:i  1 1 

TUBERCULOSIS 

^^Itiology,  228  ;  acute  miliary  tuberculosis,  232  ;  typhoid  form,  232  ;  broncho-pneu-' 
monic  form,  233  ;  scrofula  and  tuberculosis,  236  ;  tubercular  adenitis,  237  ; 
surgical  tuberculosis,  243  ;  chronic  al)scesses,  244 

CHAPTER   XIV 

THE   SPECIFIC    FEVERS 

Feverishness,  246  ;  gland  fever,  247  ;  sunstroke,  247  ;  scarlet  fever,  249  ;  surgical 
scarlet  fever,  250  ;  mild  scarlet  fever,  253  ;  malignant  scarlet  fever,  254  ;  com- 
plications, 255  ;  nephritis,  257  ;  measles,  266  ;  mild  form,  270  ;  severe  form, 
270;  Rcitheln  or  Rubella,  273 


xiv  Diseases  of  Children 

CHAPTER  XV 

THE  SPECIFIC  FEVERS  {continued) 

Diphtheria,  278  ;  pharyngeal  form,  28 1  ;  malignant,  283  ;  nasal  diphtheria,  283  ; 
laryngeal,  284  ;  wound  diphtheria,  284  ;  complications,  2S4  ;  pseudo-diphtheria, 
290  ;  epidemic  influenza,  290 ;  enteric  fever,  293  ;  complications,  297  ;  typhus, 
303  ;  varicella,  305  ;  varicella  gangrsenosa,  308  ;  vaccinia,  309  ;  complications, 
310;  varioloid,  311;  whooping  cough,  312;  complications,  315;  mumps — 
parotitis,  318;  malarial  fever,  319 


CHAPTER   XVI 

DISEASES   OF   THE   RESPIRATORY   APPARATUS 

The  thorax  in  infancy  and  childhood,  321  ;  congenital  laryngeal  stridor,  322  ;  laryn- 
gismus stridulus — child-crowing — spasm  of  the  glottis,  323  ;  spasmodic  laryn- 
gitis, 327  ;  compression  of  trachea,  328  ;  catarrhal  laryngitis,  329  ;  membranous 
laryngitis,  332  ;  tracheotomy,  336  ;  intubation  of  the  larynx,  346  ;  chronic 
laryngitis,  348  ;  papilloma  of  the  larynx,  349 


CHAPTER   XVn 

DISEASES   OF    THE   RESPIRATORY   APPARATUS  {continued) 

Bronchitis  and  catarrh,  351  ;  collapse  of  the  lung,  353  ;  bronchiectasis  and  emphy- 
sema ;  353  ;  chronic  bronchitis  and  bronchiectasis,  354  ;  broncho-pneumonia, 
355  ;  secondary  pneumonias,  357  ;  chronic  broncho-pneumonia,  358  ;  different 
types  of  pneumonias,  360  ;  croupous  pneumonia,  366  ;  gangrene  of  lung,  374 ; 
abscess  of  the  lung,  375  ;  pleurisy  and  empyema,  375  ;  asthma,  386  ;  diseases 
of  the  bronchial  glands,  387  ;  mediastinal  abscess,  388  ;  lymphadenoma,  390  ; 
chronic  tuberculosis  of  the  lungs,  390  ;  fibroid  phthisis,  393 


CHAPTER   XVni 

DISEASES   OF  THE  CIRCULATORY  SYSTEM 

Diseases  of  the  heart,  396  ;  congenital  heart  disease,  397  ;  patent  foramen  ovale, 
398  ;  patent  septum  ventriculorum,  400  ;  stenosis  of  the  pulmonary  and  tricuspid 
orifices,  400  ;  stenosis  of  the  aorta  or  mitral  valves,  401  ;  transp(»ition  of  the 
aorta  and  pulmonary  artery,  402  ;  pericarditis,  402  ;  endocarditis,  407  ;  chronic 
heart  disease,  410;  acute  myocarditis,  415  ;  mediastino-pericarditis,  417  ;  Ray- 
naud's disease,  420 


Contents  xv 

CHAPTER   XIX 

DISEASES    OK   THE    CIRCULATORY    SYSTEM    {continued) 

Nrevus,  421;  stellate  mvvus,  421;  port-wine  mark,  421  ;  cutaneous  ncevus,  422; 
subcutaneous  ncevus,  422  ;  mixed  nrevus,  422  ;  simple  nuevi,  422  ;  cavernous 
n^^vi,  422  ;  lymphatic  nrevi,  428  ;  aneurism,  430 

CHAPTER   XX 

DISEASES    OF   THE   BLOOD   AND    BLOOD-MAKING   ORGANS 

Anaemia,  432  ;  anaemia  with  oedema,  433  ;  simple  ansemia,  433  ;  idiopathic  antemia, 
434 ;  scurvy,  435  ;  enlarged  spleen,  436  ;  aneemia  splenica,  437  ;  Hodgkin's 
disease,  449  ;  leukaemia,  439  ;  hremophilia,  440  ;  purpura  simplex,  442  ;  peliosis 
rheumatica,  444  ;  diseases  of  the  retro-peritoneal  glands,  444 

CHAPTER   XXI 

SYPHILIS 
Syphilis,  446  ;  acquired  syphilis,  446  ;  hereditary  syphilis,  447 

CHAPTER   XXII 

RHEUMATISM— DIABETES 

Rheumatism,  458;  complications,  459;  chronic  rheumatism,  461  ;  arthritis  defor- 
mans, 461  ;  chronic  arthritis  with  glandular  enlargement,  462  ;  diabetes  mellitus, 
463  ;  polyuria — diabetes  insipidus,  464 

CHAPTER   XXIII 

DISEASES    OF   THE   NERVOUS   SYSTEM 

Introduction,  466  ;  clinical  examination,  467  ;  cerebral  congestion,  468  ;  tubercular 
meningitis,  468 ;  simple  meningitis,  477  ;  acute  form,  477 ;  posterior  basal 
meningitis,  479;  cerebro-spinal  meningitis,  480;  latent  form,  481  ;  chronic 
meningitis,  482  ;  endarteritis,  softening,  4S4  ;  acute  hydrocephalus,  485  ;  chronic 
hydrocephalus,  485  ;  hypertrophy  of  the  brain,  489  ;  atrophy  of  the  brain — 
sclerosis  of  the  brain,  489  ;  tumours  of  the  brain,  491  ;  tumours  of  the  cerebellum, 
493  ;  of  the  pons,  496  ;  basal  ganglia  and  internal  capsule,  496  ;  of  the  cortex, 
496  ;  of  the  frontal  lobe,  497  ;  cerebral  abscess,  498  ;  cerebral  haemorrhage,  501; 
post-partum  hsemorrhage — birth  palsy,  502  ;  cerebral  haemorrhage  occurring  after 
birth — acute  cerebral  palsy,  504  ;  medullary  haemorrhage,  510  ;  embolism,  511  ; 
thrombosis  of  the  cerebral  sinuses  and  veins,  514 

a 


xvi  Diseases  of  Children 

CHAPTER   XXIV 

DISEASES   OF    THE   NERVOUS    SYSTEM    {continued) 

Chorea,  515  ;  hemichorea,  522  ;  epilepsy,  526  ;  hysteroid  fits,  528  ;  post-hemiplegic 
epilepsy,  529  ;  infantile  convulsions — eclampsia,  532  ;  tetany,  537  ;  nystagmus, 
539  ;  head-nodding,   539  ;  head-banging,  540 ;  hysteria,  540  ;  headaches,  543  ; 

night  terrors,  545 

CHAPTER   XXV 

DISEASES    OF   THE   NERVOUS    SYSTEM    {continued) 

Speech  anomalies,  546  ;  deaf-mutism,  547  ;  acquired  deaf-mutism,  548 ;  physical 
defects  in  the  mouth,  549  ;  mental  defect,  549  ;  aphasia,  550  ;  stammering, 
550  ;  mental  affections  in  childhood,  551  ;  congenital  group,  552  ;  Mongols, 
554  ;  microcephalic,  554  ;  hydrocephalic,  555  ;  eclampsic,  555  ;  epileptic,  555  ; 
developmental  idiocy,  556  ;  accidental  or  acquired,  556  ;  backward  children, 
557  ;  idiocy  due  to  syphilis,  557  ;  cretinoid  idiocy,  559 


•  CHAPTER   XXVI 

DISEASES   OF   THE   NERVOUS    SYSTEM    {contijliced) 

Spina  bifida,  566  ;  meningocele,  570  ;  spinal  meningitis,  572  ;  paraplegia,  573  ; 
myelitis,  575  '  Landry's  paralysis,  577  ;  hereditary  ataxic  paraplegia— -Friedrich's 
disease,  577  '■>  anterior  polio-myelitis — acute  atrophic  paralysis — infantile  para- 
lysis, 578  ;  progressive  muscular  atrophy,  586  ;  peripheral  neuritis,  587  ;  pseudo- 
hypertrophic paralysis,  588  ;  juvenile  form  of  muscle  atrophy,  590  ;  muscle 
atrophy  of  the  face,  591  ;  Thomsen's  disease,  591 


CHAPTER   XXVII 

DISEASES    OF   THE    GENITO-URINARY   SYSTEM 

Abnormal  conditions  of  urine,  592  ;  lithsemia,  592  ;  hjematuria,  593  ;  intermittent 
hsemoglobinuria,  594  ;  pyuria,  594  ;  cystinuria,  594  ;  albuminuria  in  apparently 
healthy  children,  594 ;  congenital  anomalies  of  the  kidneys,  596  ;  movable 
kidney,  596  ;  renal  new  growths,  597  ;  tuberculous  kidney,  600  ;  hydronephrosis, 
601  ;  renal  calculus,  602  ;  acute  pyelitis,  602  ;  acute  nephritis,  603  ;  septic 
nephritis,  604  ;  acute  parenchymatous  nephritis,  604  ;  chronic  nephritis,  605  ; 
Addison's  disease,  607 


Contents  xvii 

CHAPTER   XXVIII 

DISEASES   OF   THE   GENITO-URINARY    SYSTEM    {continued) 

Stone  in  the  bladder,  609  ;  cystitis,  613  ;  incontinence  of  urine,  614  ;  retention,  616  ; 
malformations  of  the  genito-urinary  organs — extroversion  of  the  bladder,  617  ; 
epispadias,  620  ;  hypospadias,  620  ;  phimosis,  622  ;  balanitis,  624  ;  congenital 
paraphimosis,  624  ;  masturbation,  625  ;  oedema  of  the  scrotum,  625  ;  diseases 
of  the  external  genitals  in  females,  625  ;  vulvitis,  625  ;  noma  pudendi,  627  ; 
irritable  mamma,  627  ;  abnormalities  in  the  descent  of  the  testicles,  627  ;  super- 
numerary testicles,  631  ;  congenital  displacement  or  hernia  of  the  ovary,  631  ; 
acute  orchitis,  631  ;  syphilitic  testitis,  632  ;  tubercular  disease,  632  ;  tumours  of 
the  testis,  633  ;  hydrocele,  633  ;  hydrocele  in  girls,  634  ;  varicocele,  635  ; 
ovarian  tumours,  635 

CHAPTER   XXIX 

DISEASES    OF   THE    BONES 

Diseases  of  the  bones,  636  ;  acute  periostitis,  637  ;  acute  osteomyelitis,  645  ;  acute 
epiphysitis,  646  ;  chronic  periostitis,  648  ;  chronic  circumscribed  osteomyelitis, 
652  ;  chronic  diffuse  osteomyelitis,  654  ;  strumous  dactylitis,  657  ;  syphilitic 
dactylitis,  659  ;  leontiasis  ossea,  659 

CHAPTER    XXX 

DISEASES   OF   THE  JOINTS 

Tubercular  disease  of  the  shoulder,  664  ;  disease  of  the  elbow-joint,  664  ;  of  the 
wrist,  665  ;  of  the  ankle,  666  ;  acute  synovitis,  667  ;  pysemic  joint  disease,  668  ; 
exanthematous  synovitis,  668 ;  chronic  rheumatic  arthritis,  669 ;  syphilitic 
synovitis,  669  ;  acute  suppurative  arthritis  of  infants,  670  ;  acute  tuberculous 
synovitis,  672  ;  erasion,  676  ;  excision,  677  ;  sacro-iliac  disease,  684  ;  disease  of 
the  temporo-maxillary  joint,  685  ;  hysterical  joints,  685 

CHAPTER   XXXI 

HIP   DISEASE 
Chronic  hip  disease,  687  ;  acute  hip  disease,  690 

CHAPTER   XXXII 

SPINAL  DISEASE 
Caries  of  the  spine,  713  ;  costo- vertebral  disease,  726 


xviii  Diseases  of  Children 


CHAPTER   XXXIII 

CLUB-FOOT,    DEFORMITIES    OF    LIMBS,    ETC. 

Talipes  equino-varus,  727  ;  T.  valgus,  728  ;  T.  equinus,  729  ;  paralytic  or  acquired 
talipes,  736  ;  flat-foot,  738  ;  wry-neck  or  torticollis,  740  ;  deficiencies  of  mus- 
cles, 743  ;  tenosynovitis,  743  ;  various  congenital  malformations,  743  ;  super- 
numerary digits,  746  ;  club-hand,  747  ;  web-fingers,  749  ;  congenital  rigidity  of 
joints  and  contractions,  749  ;  congenital  dislocations,  750 


CHAPTER   XXXIV 

DISEASES    OF   THE   NOSE 

Acute  catarrh,  754  ;  chronic  catarrh,  754  ;  nasal  polypi,  756  ;  malformations,  756  ; 
epistaxis,  757  ;  nasal  deformity,  757 

CHAPTER   XXXV 

DISEASES    OF   THE   EAR 

Diseases  of  the  external  ear,  758;  affections  of  the  external  meatus,  758  ;  inflamma- 
tion of  the  middle  ear,  759  ;  of  the  labyrinth,  762  ;  intracranial  abscess,  762 

■  CHAPTER   XXXVI 

TUMOUR    GROWTH    IN    CHILDHOOD 

Sarcomata,  764  ;  neuroma,  765  ;  enchondroma,  766  ;  exostosis,  767  ;  cystic  tumours, 
767;  fatty  growths,  770;  giant  foot,  771;  compound  congenital  tumours,  77^; 
congenital  sacral  tumour,  773  ;  lymphoma,  775  ;  cystic  growths  of  the  jaws,  776 


CHAPTER   XXXVII 

DISEASES    OF   THYROID   AND   THYMUS 
Acute. enlargement  of  the  thyroid,  777  ;  goitre,  777  ;  thymus,  778 

CHAPTER   XXXVIII 

DISEASES   OF   THE   SKIN 

Eczema,  780 ;  impetigo,  787  ;  seborrhoea,  787  ;  erythematous  eruptions,  788  ;  roseola, 

788  ;    erythema    scarlatiniforme,   788 ;    chilblains,    789  ;    erythema   multiforme, 

789  ;  erythema  nodosum,  .789  ;  urticaria,  790 ;  urticaria   papulosa,  790  ;  lichen 


Contents  xix 

scrofulosus,    790  ;  psoriasis,  791  ;  pityriasis  rubra,  791  ;    miliaria — sudamina, 

791  ;  miliaria  rubra,  791  ;  pemphigus,   791  ;  dermatitis,  792  ;  drug  eruptions, 

792  ;  tinea  tonsurans,  793  ;  tinea  circinata,  794  ;  alopecia  areata,  796  ;  favus, 
796  ;  scabies,  796  ;  pediculosis,  796  ;  flea-bites,  797  ;  midge-bites,  797  ;  harvest 
bug,  797  ;  simple  onychia,  797  ;  onychia  maligna,  797  ;  lupus,  798  ;  papilloma, 
799  ;  hairy  and  pigmented  moles,  799 


CHAPTER    XXXIX 

INJURIES,     SHOCK,     H/EMORRHAGE,     ETC. 

Injuries  to  the  head,  Soo  ;  traumatic  cephalhydrocele,  800  ;  fracture  of  the  base  of 
the  skull,  801  ;  injuries  to  the  chest,  801  ;  injuries  to  the  abdomen,  801  ;  injuries 
of  the  limb,  801  ;  greenstick  fractures,  802  ;  ununited  fractures,  S02  ;  separation 
of  the  epiphyses,  803  ;  primary  amputations,  812  ;  primary  resections,  812  ;  ' 
dislocations,  S12  ;  burns  and  scalds,  813;  shock,  814;  loss  of  blood,  S14  ; 
pain,  S14  ;  septic  diseases,  815 

CHAPTER    XL 

AN/ESTHETICS     FOR     CHILDREN 

General  anaesthesia,  816  ;  choice  of  an  anaesthetic,  818  ;  local  anaesthesia,  818  ; 
cocaine,  818 ;  nitrous  oxide,  818  ;  chloroform,  819 ;  ether,  819  ;  A.  C.  E. 
mixture,  820  ;  preparation,  820  ;  vomiting,  823  ;  anaesthetics  in  special  opera- 
tions, 823  ;  accidents,  824  ;  Calot's  operation,  825 

APPENDIX o         .     827 

FORMULA         .         .         .     ■ 865 

INDEX        ....,....-.,         =         .     877- 


LIST   OF   ILLUSTRATIONS 


PLATES 


PLATE  I'AG 

I.      Hip  disease,  with  '  travelling  acetabulum '      .  .  .     .     lo  face  p.   689 

II.      Skiagram  of  the  arm  and  chest  wall  in  a  case  of  myositis 

ossificans,  showing  the  bony  spines  and  plates  in  the  muscles  ,,  743 

III.  Skiagram  of  a  case  of  club-hand,  with  arrest  of  development 

of  the  radial  (praeaxial)  border  of  the  limb        ...  ,,  747 

IV.  '  Congenital  dislocation  '   of  the   hip.     The  acetabulum   is 

seen  far  below  the  head  of  the  femur .         .  .         .     .  ,,  751 

V.      'Congenital  dislocation'  of  the  hip,  the  fellow  to  Plate  IV.  ,,  752 

W.      Beatrice  D. ,  set.  2^  years.      Separation    of  the  whole  lower 
epiphysis  of  the  humerus,  with  inward  displacement  of  a 
vertical   split  in  the  shaft.     The  diaphysis   projects   out- 
wards.     Loss  of '  carrying  angle '    .  .  .  .  .  , ,  806 

VII.      Separation  of  the  lower  epiphysis  of  the  humerus,  with  back- 
ward displacement     .  .  .         .  .         .  .     .  ,,  806 

VIII.      Separation  of  lower  epiphysis  of  humerus,  with  T  fracture. 
Subluxation  of  radius  forwards.      Injury  four  years  ago. 
Good  mobility.     Boy  set.  11  years  .         .  .  .  .  ,,  806 

IX.     Separation  of  the  capitellar  in  a  girl  let.  7  years.     There  \\as 
mobility  through  about  70°,  and  good  power  of  pronation 
and  supination.     A  points  to  loose  fragment         .  .      .  j,  806 

X.      Separation   of  the  lower    epiphysis  of  the   radius  in   a  boy 

ffit.  10  years  .........  ,,  807 

XI.      Separation  of   radial  epiphysis,   with  arrest  of  growth  two 
years  later.     Boy  fet.  12  years.     A  centre  of  ossification 
for  the  styloid  process  of  the  ulna  exists       .  .  .      .  ,,  S07 

XII.     Separation  of  the  lower  epiphysis  of  the  femur,  with  vertical 

fracture  of  the  shaft.      From  a  young  man  iTst.  18  years     .  ,,  S08 

XIII.     Fracture    above  epiphysial  line  of  lower   end  of  humerus. 
Loss  of  '  carrying  angle. '     Boy  ■x'l.  6  years.     Injury  four 
months  ago        .  .         .         .  .  .  .  .     .  ^,  810 

XIV..     Fracture  of  neck  of  femur,  possibly  diastasis.     Boy  ret.   11 

years ,,  811 


XXll 


Diseases  of  Children 


IN   TEXT 


FIG. 
I. 
2. 

3- 
4- 
5- 
6. 

7- 


12. 

13- 
14. 

15- 
16. 

17- 
18. 
19. 
20. 
21. 
22. 

23- 

24. 

25- 

26. 
27. 
28. 
29. 

SC- 
32- 

33- 
34- 
35- 
36. 
37- 
38. 
39- 
40. 
41. 
42. 

43- 

44. 


Stomach  of  a  newly  born  infant  (natural  size) 

Weight  chart,  showing  normal  weights  during  first  year 

Lower  jaw  of  an  infant  at  birth,  showing  dental  sacs 

Lower  jaw  of  a  child  about  three  years  of  age 

Meningeal  haemorrhage  in  an  infant 

Double  cephalhjematoma  . 

Section  of  a  cephalhasmatoma 

Section  of  an  ileo- umbilical  diverticulum 

Bottle  for  allowing  milk  to  stand    . 

Infant's  feeding-bottle 

Fungus  of  thrush  .... 

Deformity  of  mouth  due  to  cancrum  oris 

Vertical  section  of  human  tonsil 

Temperature  chart  of  epidemic  tonsillitis 

Congenital  stenosis  of  the  pylorus  . 

Hour-glass  constriction  of  stomach     . 

Thread  worm         .... 

Eggs  of  thread  worm         ... 

Ileo-csecal  intussusception 

Intussusception  removed  by  operation 

Longitudinal  section  of  fig.  20 

Scheme  of  lines  of  union  of  face 

Double  incomplete  hare-lip    . 

Severe  double  hare-lip 

Diagrams  of  hare-lip  operations 

Macrostoma      ..... 

Branchial  fistulee  in  a  girl 

Supernumerary  auricle  in  neck  . 

Tracing  of  chest  wall  of  a  rickety  boy 

Enlargement  of  epiphyses  of  lower  end  of  radius  and  ulna 

Section  through  radius  of  case  figured  in  fig.  30 

Longitudinal  section  through  the  junction  of  a  rib  and  its  cartilage  from 

rickety  child  .... 

Transverse  section  through  the  shaft  of  the  ulna  of  a  rickety  child 
Rickety  deformity  of  the  femora         .... 
Shows  the  attitude  assumed  by  child,  fig.  34  . 
The  same  child  as  that  figured  in  34,  limbs  straightened 
A  child  aged  7  years,  showing  extreme  stunting 

Rickety  curvature  of  the  spine 

A  case  of  knock-knees  .         .         .         .         .         . 

A  child  sitting  cross-legged         .        • . 

A  case  of  bow-legs         .         .         .         .         .  . 

A  case  of  severe  rickets      ...... 

Thomas's  splint  for  genu  valgum    .... 

Lateral  curvature  of  the  spine 


List  of  Illii^strations 


XXlll 


FIG. 

45- 
46. 
46a, 

47- 
48. 

49- 
50- 
51- 
52. 
53- 
54- 
55- 
.  56. 
57- 
58. 
59- 
60. 
61. 
62. 

63- 
64. 
65. 
66. 
67. 
68. 
69. 
70. 

71- 

72. 

73- 
74- 
75- 
76. 

77- 
78. 

79- 
80. 
81. 
82. 

83. 
84. 
85. 
86. 
87. 
88. 
89. 
90. 
91. 
92. 


Reclining  board  for  lateral  curvature 
Miliary  tubercles  of  the  choroid 

Tubercular  ulceration  of  skin  of  foot     . 
Temperature  chart  of  acute  ostitis  in  an  infant 

,,  ,,       erythema  nodosimi 

,,  ,,       scarlet  fever 

,,  ,,       mild  scarlet  fever  . 

,,  ,,       malignant  scarlet  fever 

,,  ,,        post-scarlatinal  nephritis 

,,  ,,       cases  of  measles 

,,  ,,       measles  with  broncho-pneumonia 

,,  ,,       mild  enteric  fever 

,,  ,,        enteric  fever 

,,  ,,  ,,         ,,     with  peritonitis 

,,  ,,       typhus  fever 

,,  ,,       chicken  pox 

\^aricelia  gangrenosa     ..... 
Temperature  chart  of  modified  smallpox     . 
Anatomy  of  child's  trachea     .... 
Parker's  tracheotomy  tube  .... 

O'Dwyer's  intubation  apparatus 
O'Dwyer's  extractor  ..... 

Papilloma  of  the  larynx  .... 

Temperature  chart  of  broncho-pneumonia  . 

,,  ,,       acute  fatal  broncho-pneumonia 

, ,  , ,       a  case  of  acute  lobar  pneumonia 

,,  ,,       croupous  pneumonia 

,,  ,,  ,,  ,,  treated  with  cold  bath 

,,  ,,       pleuro-pneumonia  followed  by  empyema 

Deformity  of  chest  due  to  empyema  . 
Caseous  glands  in  the  mediastinum 
Plan  of  foetal  circulation    .  '       . 
Stenosis  of  pulmonary  artery  . 


Temperature  chart  of  acute  endocarditis 

Acute  endocarditis  of  mitral  valves     . 

Chronic  mediastino-pericarditis 

Mixed  naevus  of  face 

Nasvus  of  face        .... 

Orbital  nrevus  ..... 

Arterio-venous  varix 

Nrevus  lipomatodes  .... 

Degenerated  nsevus  of  scalp    . 

Lymphatic  ntevus  of  foot  . 

Gangrene  of  the  leg  following  embolism 

Fissures  around  the  mouth  in  congenital  syphilis 

Congenital  syphilis  ..... 

Destruction  of  the  nose  in  congenital  syphilis 

Diseases  of  bone  in  congenital  syphilis    . 


I'AGR 

226 


XXIV 


Diseases  of  Children 


FIG. 

93- 
94- 
95- 
96. 

91- 
98. 

99- 
100. 

lOI. 

102. 
103. 
104. 
105. 
106. 
107. 
108. 
109. 
no. 
III. 

112. 

113- 

114. 

115- 
116. 
117. 
118. 
119. 
120. 
121. 
122. 
123. 
124. 
125. 
126. 
127. 
128. 
129. 
130. 

131- 
132. 

133- 
134- 
135- 
136. 
137- 
138. 
139- 
140. 
T41. 


Syphilitic  epiphysitis  .... 

Chrouic  arthritis  with  glandular  enlargement 

Tracing  of  'Cheyne-Stokes'  respiration 

Microcephalic  infant 

Meningo-encephalitis 

Sclerosis  of  brain  .... 

Chronic  hydrocephalus 


Atrophy  of  the  left  side  of  the  cerebrum 
Transverse  section  of  the  cerebrum 
Spastic  paralysis         .  .  .  . 

Results  of  tenotomy  in  spastic  paralysis 
Spastic  paralysis,  mental  feebleness    . 
Section  of  brain,  showing  blood-cysts 


Brain,  showing  effects  of  old  meningeal  hfemorrhage 
Medulla,  showing  haemorrhage 

Transverse  section  of  medulla,  showing  hsemorrhage 
Section  of  brain,  showing  effects  of  embolism     . 
Cyst  formed  in  brain  as  the  result  of  embolism 
Tetany 


Hysterical  hemiplegia 
Mongol  imbecile   . 
Cretin 


after  treatment 


A  case  of  cured  spina  bifida,  with  talipes    . 
Section  through  a  spina  bifida  cured  by  injection 
Spontaneous  cure  of  spina  bifida 
Occipital  meningocele  .... 
Frontal  meningocele  .... 

Acute  atrophic  paralysis 


Acute  muscular  atrophy 
Pseudo-hypertrophic  paralysis 


of  the  bladder 


Growth  in  the  kidney        .... 

Congenital  renal  sarcoma 

Result  of  a  plastic  operation  for  extroversion 

Undescended  testis  seen  as  a  swelling  in  the  inguinal  canal 

Diagram  showing  the  commoner  fotms  of  hydrocele  of  the 

Acute  periostitis  of  the  femur 

Overgrowth  of  the  bones  of  the  right  leg  .         .         . 

Syphilitic  disease  of  both  tibicis  ..... 
Epiphysitis  of  the  upper  end  of  the  right  humerus  . 


in  a  boy 
vaginal  process 


649 
653 


List  of  Illustrations 


XXV 


142. 

143- 
I-14- 
'45- 
146. 

M7- 
14S. 

149 
150. 
151. 
152. 
I53. 
154- 
155- 
156- 
157. 
15S. 

159- 
160. 
i6r. 
162. 
163. 
164. 
165. 
i65. 
167. 
168. 
169. 
170. 
171. 
172. 

173- 
174. 

175- 
176. 

177- 
17S. 
179. 
iSo. 
iSi. 
182. 
183. 
184. 
185. 
186. 
187. 
18S. 
1S9. 
190. 


Multiple  tuberculous  dactylitis   ....... 

Overgrowth  of  thumb  as  the  result  of  tuberculous  disease 
Results  of  tuberculous  dactylitis         ...... 

Tuberculous  disease  of  the  wrist     ...... 

Tuberculous  disease  of  the  ankle  joint        ..... 

Congenital  syphilitic  synovitis  of  both  wrists  .... 

Showing  the  results  of  erasion  of  knee        ..... 

Showing  the  result  of  premature  use  of  the  limb  after  operation 
Splint  for  disease  of  the  ankle  and  tarsus  .... 

Resection  of  the  tarsus       ........ 

Showing  the  result  of  excision  of  the  os  calcis 

Diagram  showing  the  parts  most  frequently  affected  in  hip  disease 

Disease  of  head  of  femur        ....... 

Section  of  the  head  of  femur,  showing  disease    . 
Specimen,   showing  disease  of  the  acetabulum 
Lordosis  in  hip  disease      ...... 

Position  of  the  limb  in  the  second  stage  of  hip  disease 
Side  view  of  the  same         ...... 

Bryant's  splint         ..... 

Method  of  applying  extension  in  hip  disease 
Thomas's  hip  splint  applied   . 


Result  of  excision  of  the  hip  . 

Caries  of  the  spine      .... 

Attitude  in  spinal  caries 

Jury-mast  for  spinal  caries 

Patterns  of  Thomas's  splints  for  spinal  disease 

Caries  of  the  spine  treated  with  Thomas's  spl 

Severe  talipes  equino-varus 

Very  severe  talipes  equino-varus 

Talipes  produced  by  '  bad  packing  ' 

Little's  tin  splint        .... 

Artificial  muscle   applied 

Little's  tin  talipes  shoe 

Acquired  talipes     .... 

Acquired  talipes  calcaneus 

Kiat-foot 

Artificial  muscle  for  flat-foot 

Congenital  wry-neck 

Artificial  muscle  for  congenital  wry-neck 

Double  thumb         . 

Intra-uterine  amputation    . 

Arrest  of  development  of  limb 

Clnb-hand  ..... 

Double  club-hand  .... 

Genu  recurvatum  and  talipes  calcaneus       ... 

Abnormal  position  in  utero,  causing  genu  recurvatum,  &c. 

Congenital  dislocation  of  both  hips    . 


Diseases  of  Children 


FIG. 

191.  Sarcoma  of  lower  jatv  and  eyeball  . 

192.  Enchondroma  of  spine  and  fingers     . 

193.  Multiple  enchondromata  of  finger  . 

194.  Hygroma  of  neck  with  macroglossia  . 
195-.  Congenital  serous  cyst  of  back 

196.  Dermoid  cyst  of  orbit         .... 

197.  ,,  ,,  forehead 

198.  ,,  ,,      in  lachrymal  fissure 

199.  Myxo-lipoma  of  breast  .... 

200.  Giant  foot  ...... 

20r.  Congenital  cystic  tumour  of  groin  . 

202.  Congenital  sacral  tumour  .  .  . 

203.  Section  of  congenital  sacral  tumour 

204.  Lymphoma  of  neck   ..... 

205.  Cystic  bronchocele  .... 

206.  Hairy  mole  of  face  and  scalp      ..... 

207.  .Separation  of  the  upper  epiphysis  of  the  right  humerus 

208.  Plan  of  the  development  of  the  humerus    . 

209.  Separation  of  trochlear  epiphysis  of  humerus 

210.  Arrest  of  growth  of  the  radius    ..... 

211.  Separation  of  the  lower  epiphysis  of  the  radius 

212.  Separation  of  lower  epiphysis  of  left  femur 

213.  Dislocation  of  the  patella         ..... 

214.  Freeman's  Pasteurizing  apparatus        .... 

215.  Short  large  calibre  tubes         ..... 

216.  Built-up  head  for  granulations  ....... 

217.  New  York  Orthopnedic  Hospital  brace  for  knock-knee  and  bow-legs 

218.  Knight's  bow-leg  brace  ......... 

219.  Boston  Children's  Hospital  brace  for  bow-legs  .... 

220.  The  Davis-Taylor  long  traction  hip-splint       ..... 

221.  Bradford-Goldthwaite  brace  for  correcting  deformity  at  the  knee 

222.  Taylor's  spinal  brace  with  chin-cup         ....;. 

223.  Whitman's  flat-foot  support        ....... 

224.  Shaffer's  flat-fogt  support 


PAGE 
764 

766 
767 
767 
768 
769. 
770 
771 

771 

772: 

773' 
77+ 
776 
77S 
7q8- 
S04- 
805 
S06 
8o6. 
S07 
.  80S 

813 
S30 

833. 
835 
83^ 
836, 
S3& 
844 

845 
847 
849 
850 


DISEASES    OF    CHILDREN 


CHAPTER    I 

THE   PHYSIOLOGY   OB^    INFANCY    AND    CHILDHOOD 

The  Periods  of  Early  Kife. — The  life  of  man  is  naturally  divided  into 
three  great  epochs — viz.  a  period  of  Growth  and  Development^  oi  Maturity^ 
and  of  Decline. 

The  first  division  includes  the  periods  of  early  life,  when  those  series  of 
operations  are  in  progress  by  which  the  ovum  or  primitive  germ  is  trans- 
formed into  the  complete  organism  ;  it  may  be  subdivided  into  Intra-titerinc 
Life.,  bifancy^  Childhood.,  Youth.,  and  Adolescence. 

Intra-uterlne  life. — ^During  this  epoch  the  embryo  depends  entirely 
upon  its  parent  for  all  its  wants.  The  maternal  blood  supplies  it  with 
material  for  constructive  purposes,  carries  away  its  waste  products,  and 
renders  unnecessary  the  maintenance  of  an  independent  temperature.  It  is 
clearly  a  time  of  great  importance  to  the  future  being,  and  it  is  necessary 
that  this  development  should  take  place  under  healthy  conditions,  inasmuch 
as  it  is  physiologically  impossible  for  an  unhealthy  or  weakly  mother  to  supply 
the  wants  of  the  embryo,  and  any  failure  in  the  nutritive  powers  of  the  mater- 
nal blood  is  certain  to  leave  its  stamp  on  the  future  development  of  the  child. 
An  infant  may  come  into  the  world  fairly  well  developed  and  plump,  from 
the  presence  of  more  or  less  stored-up  fat,  in  spite  of  the  weakly  state  of  the 
mother's  health,  but  it  is  almost  certain  sooner  or  later  to  exhibit  tendencies 
to  disease  in  the  direction  of  the  stock  from  whence  it  springs.  Not  only 
may  the  embryo  owe  a  weakly  building-up  of  its  tissues  to  its  mother,  but  it 
may  actually  share  maternal  disease.  The  foetus  may  suffer  from  endo- 
carditis originating  in  a  rheumatic  state  of  its  parent,  and  this  lesion  affecting, 
as  it  usually  does,  the  right  side  of  the  heart,  may  lead  to  malformations, 
which  are  only  too  likely  to  cut  short  its  career.  From  its  parents  also  the 
foetus  may  receive  the  virus  of  syphilis,  from  which  it  may  suffer  during  its 
embryonic  life  or  after  birth.  It  may  receive  an  inheritance  of  tuberculosis 
or  epilepsy,  or  a  tendency  to  gout  or  rheumatism.  During  foetal  life  many 
anomalies  may  arise  from  arrested  development  or  an  overgrowth  in  certain 
directions  :  cleft  palate  and  hare-lip  are  instances  of  the  former,  and  super- 
numerary fingers  and  naevoid  growths  of  the  latter. 

Infancy. — The  Romans  used  the  word  infans  in  its  widest  sense,' and 
though,  as  its  derivation  implies,  it  was  originally  applied  to  those  who  could 

B 


2  The  Physiology  of  Infancy  and  Childhood 

not  speak,  it  came  to  be  employed  by  them  for  children  of  much  older  years. 
The  terms  infancy^  pre7niere  enfance  and  Siiiigliiigsperiode  are  most  usually 
applied  to  the  first  seven  or  eight  months  of  life,  the  time  during  which  the 
infant  is  nursed  at  the  breast,  and  before  the  eruption  of  the  milk  teeth.  It 
is,  however,  used  by  some  writers  to  include  the  whole  of  the  first  year. 
Within  the  first  week  or  two  of  life  the  infant  has  often  to  contend  with  con- 
ditions which  ai'e  peculiar  to  this  period,  inasmuch  as  they  depend  in  one 
way  or  another  on  the  act  of  birth.  It  may  be  born  asphyxiated  in  con- 
sequence of  strangulation  by  the  cord  or  pressure  on  the  head  ;  various 
injuries  producing  heematomas  may  take  place  ;  or  there  may  be  septic  in- 
fection in  connection  with  the  umbilical  cord.  The  change  from  placental 
alimentation  to  the  digestion  of  food  in  the  infant's  stomach  is  a  time  of 
peculiar  danger,  especially  if  artificial  food  is  given,  and  the  mortality 
of  infants  is  much  greater  during  the  first  week  of  life  than  at  any  other 
period. 

During  the  first  few  months  of  infancy,  life  is  not  so  purely  vegetative  as 
it  is  during  the  intra-uterine  period,  yet  the  mental  faculties  are  in  abeyance 
and  the  movements  mostly  involuntary  or  reflex. 

One  consequence  of  the  undeveloped  condition  of  the  higher  or  inhibitory 
centres  is  that  the  reflex  centres  are  less  under  control  than  in  later  years,  so 
that  disorderly  reflex  movements  in  the  form  of  convulsions  are  liable  to  take 
place  on  the  slightest  provocation.  Growth  at  this  period  is  extremely  rapid, 
the  weight  more  than  doubling  itself  during  the  first  six  months  of  life,  and  a 
great  strain  is  thus  thrown  on  the  alimentary  system  ;  the  lymphatic  and 
blood-forming  organs  are  also  exceedingly  active.  It  is  not  surprising,  there- 
fore, that  the  diseases  which  are  most  common  and  fatal  at  this  period  are 
those  connected  with  digestion  and  absorption.  The  infant  requires  much 
rest,  and,  indeed,  divides  its  time  for  the  most  part  between  feeding  and 
sleeping.  It  is  during  this  period  that  '  wasting,'  '  marasmus,'  or  '  atrophy  '  is 
so  common,  a  result  of  chronic  catarrh  of  the  intestinal  tract  and  a  con- 
sequent impairment  of  the  digestive  organs. 

Cbildtaood. — The  eruption  of  the  milk  teeth  marks  an  epoch  in  early 
life,  the  term  childhood  being  applied  to  the  period  commencing  with  the 
first  dentition  and  ending  with  the  commencement  of  the  second,  at  the 
sixth  or  seventh  year.  The  terms  seconde  enfaiice  and  Kinderalter  are  used 
in  a  similar  sense.  Growth  at  this  period  continues  to  be  active,  though  not 
proceeding  at  the  same  rate  as  during  infancy,  but  disturbances  of  the  ali- 
mentary system  are  comm.on,  and  children  quickly  waste  if  digestion  and 
absorption  are  interfered  with. 

The  osseous  and  muscular  systems  are  developing  so  that  by  the  end  of 
the  first  year  the  child  can  crawl  or  even  walk  with  help.  It  is  at  the  com- 
mencement of  this  period  that  rickets,  a  disease  so  intimately  associated 
with  indigestion,  often  makes  its  appearance.  The  mental  faculties  are 
opening  out  as  the  brain  develops,  and  the  infant  begins  to  recognise  its 
friends  and  call  them  by  name.  During  the  period  of  dentition  nervous 
disturbances  are  common,  and  the  lesions  giving  rise  to  infantile  paralysis 
are  apt  to  take  place.P 

Voutb. — The  terms  youth^  Jez/nesseand  Knabenalierar^  generally  applied 
to  the  period  commencing  at  the  second  dentition  and  ending  at  puberty,  or 


Youth — Respiration  3 

about  tlic  fourteenth  year.  During  this  time  tlic  milk  teeth  are  re])laccd  by 
the  permanent  set,  the  bones  become  more  sohd  and  the  muscles  better 
developed,  while  the  mental  faculties  are  exceedingly  acute  and  the  mind 
readily  acquires  knowledge.  As  puberty  approaches,  the  voice  becomes 
deeper  and  the  sexual  organs  undergo  a  marked  increase  of  development. 
During  this  j^eriod,  in  which  scholastic  education  is  carried  on,  the  memory 
is  exceedingly  retentive,  perhaps  more  so  than  at  any  other  time.  Children 
at  this  period  easily  'outgrow  their  strength,'  the  nervous  system  is  readily 
upset,  as  is  evidenced  by  the  frequency  of  chorea,  and  the  alimentary  canal 
is  apt  to  suffer  from  chronic  catarrh. 

Respiration. — During  intra-uterine  life  the  respiration  of  the  fcttus  is 
carried  on  by  means  of  the  placenta.  The  blood  of  the  foetus— as  far  as 
oxygen  is  concerned — is  supplied  in  a  far  more  imperfect  manner  through 
the  maternal  blood,  than  when  after  birth  the  oxygen  is  taken  direct  from 
the  air  in  the  vesicles  of  the  lungs.  Inasmuch  as  the  foetus  has  no  inde- 
pendent temperature  to  maintain,  and  its  life  is  spent  in  continuous  sleep, 
its  tissues  require  far  less  oxygen  than  it  does  after  birth.  This  condition 
of  things  induces  a  tolerance  of  oxygen  starvation,  much  greater  than  in 
adults,  that  frequently  stands  it  in  good  stead  during  the  act  of  birth,  when 
the  placental  circulation  is  perhaps  interfered  with  through  pressure  on  the 
umbilical  cord,  and  pulmonary  respiration  as  yet  is  not  possible.  Infants 
are  often  born  in  a  condition  of  asphyxia,  especially  after  severe  labours,  and 
have  been  known  to  survive  without  either  placental  or  pulmonary  respira- 
tion for  ID  to  15  minutes,  and  infants  may  live  for  many  hours,  or  even  days, 
with  the  greater  part  of  their  lungs  in  an  unexpanded  state.  The  same 
tolerance  of  a  venous  condition  of  blood  occurs  in  other  newly  born  animals  ; 
thus  Brown-Sequard  has  shown  that  a  newly  born  mouse  will  recover  after 
an  immersion  of  10  minutes  in  water,  a  newly  born  guinea-pig  after  12 
minutes,  while  an  immersion  of  3  to  3!  minutes  is  fatal  to  the  adult  animals. 

In  the  newly  born  the  respirations  amount  to  about  44  per  minute  ; 
during  the  early  months  of  life  they  vary  from  35  to  40  per  minute  ;  at  the 
end  of  the  first  year  and  commencement  of  the  second  they  have  fallen  to 
about  28  ;  during  the  third  and  fourth  years  they  are  about  25  ;  by  the 
fifteenth  year  they  have  fallen  to  20  ;  in  the  adult  they  vary  from  16  to  20. 
Infants  and  children,  as  might  be  expected,  give  off  absolutely  less  carbonic 
acid  than  do  adults,  but  relatively  more.  This  may  perhaps  be  accounted 
for  by  their  greater  activity  (see  page  4). 

The  absorption  of  oxygen  is  also  relatively  greater  in  childhood  than  in 
adult  life  ;  the  oxygen  in  the  exhaled  carbonic  acid  does  not  represent  all 
the  inhaled  oxygen,  the  proportion  retained  being  greater  in  childhood  than 
in  adult  life. 

In  the  infant  and  during  the  first  three  years  of  life  the  type  of  respira- 
tion is  the  abdominal,  the  diaphragm  beingthe  chief  muscle  used  in  tranquil 
respiration,  the  abdomen  rising  and  falling,  and  the  ribs  moving  but  little. 
Later  the  costo-inferior  type  is  present,  respiration  takes  place  by  means  of 
the  intercostals,  and  also  by  the  diaphragm,  the  chest  expanding  and  the 
abdomen  moving  slightly.  In  girls  towards  puberty  the  costo-superior  type 
is  present,  the  upper  part  of  the  chest  moves  freely,  the  lower  part  and  the 
abdomen  hardly  at  all. 


3  to   4 

years     . 

.     about  450  c.c. 

5    „    7 

)> 

„      goo  c.c. 

8  „  lo 

■>■) 

„  1,300  c.c. 

4  The  Physiology  of  Infancy  and  Childhood 

The  vital  cubic  capacity  of  the  lungs  is  smaller  in  proportion  to  their 
height  in  children  than  in  adults.  This  is  due  in  part  to  the  relative  small- 
ness  of  their  lungs  and  to  the  greater  elasticity  and  flexibihty  of  their  chest 
walls. 

According  to  Schnepf  and  Wintrich  the  vital  cubic  capacity  at  different 
ages  is  shown  by  the  following  table  : 

II  to  1 2  years  .  .  about  1,800  c.c. 
13  „  14  „  •  •  „  2,200  c.c. 
In  adults  (average)     „      3,300  c.c. 

With  regard  to  the  amount  of  carbonic  acid  given  out  by  children,  the 
following  account  of  an  experiment  made  by  the  late  Dr.  Angus  Smith,  of 
Manchester,  is  of  interest.  We  cjuote  his  own  words  :  '  Four  children,  three 
boys  of  6,  7,  and  8  years  respectively,  and  one  girl  of  7,  were  put  into  the 
lead  chamber  which  was  made  for  similar  experiments,  and  in  order  to 
observe  them  more  carefully  Dr.  Ashby  sat  beside  them.  They  were 
extremely  quiet,  and  the  amount  of  carbonic  acid  given  out  was  exactl}'  one- 
half  of  that  which  experiment  had  given  me  in  previous  years  for  a  healthy 
man  of  moderate  strength.  The  amount  given  out  by  Dr.  Ashby  was 
estimated  in  a  separate  experiment,  and  subtracted  from  that  given  out  by 
the  children,  which  was  equal  in  amount  to  o'36i  of  a  cubic  foot  per  hour  for 
each.  The  children  were  then  put  in  by  themselves  and  became  very 
riotous  and  active,  causing  the  carbonic  acid  to  rise  up  for  each  to  o*53i  of 
a  cubic  foot.  They  were  then  put  in  again  and  requested  to  be  very  quiet. 
They  had  a  few  cards  to  play  with,  and  talked  a  great  deal,  but  were  bodily 
pretty  still,  upon  which  the  carbonic  acid  fell  down  nearly  to  the  first  amount 
— viz.  0"4i39  of  a  cubic  foot.  We  find  that  talking  raised  the  amount  of 
carbonic  acid  only  0-0529  of  a  cubic  foot,  whilst  jumping  and  laughing- 
raised  it  o'i687,  or  about  three  times  as  much.' 

The  circumference  of  the  chest  on  an  average  measures : 

6  years 22  inches 

7  9-7-1 

9      „       24      „ 

10      „        241    „ 


Chang-es  in  the  Circulation  after  Birth. — The  cessation  of  the  placental 
circulation,  the  inflation  of  the  lungs  with  air,  and  consequently  the  increased 
amount  of  blood  passing  through  the  pulmonary  artery,  lead  to  a  gradual 
shrinking  and  obliteration  of  the  various  foetal  passages — viz.  the  vessels  of 
the  cord,  the  ductus  venosus,  ductus  arteriosus,  and  foramen  ovale.  These 
changes  commence  after  the  first  few  respirations  have  been  taken,  and 
within  a  week  or  ten  days  these  passages  are  closed.  Not  infrequently, 
however,  one  or  other  of  them  remains  open  for  a  much  longer  period,  this 
being  especially  true  of  the  foramen  ovale.  In  62  cases  under  2  years  of 
age  noted  by  Parrot,  it  was  only  completely  obliterated  in  four  ;  and  of  52 
cases  between  2  and  9  years,  in  26  only  was  it  completely  closed. 

With  regard  to  the  ductus  arteriosus,  Parrot  found  that  of  187  cases  of 
I  month  to  3  years,  in  46  it  was  open,  in  18  it  was  partially  closed,  and  in  J19 


Birth  .     .     . 

.     .      13  inches 

6  months      . 

■     •      17       „ 

2       „ 

•     •      19      „ 

2  years    .     . 

.     .     20      „ 

4      „ 

•      ■      2I|     „ 

Blood — Pulse  5 

it  was  obliterated.  The  ductus  venosus  is  mostly  obliterated  within  three 
days  ;  according  to  Quincke  its  remaining  partially  open  gives  rise  to 
icterus. 

Blood. — During  the  last  few  years,  many  observations  have  been  made 
of  the  blood  of  the  newly  born  and  also  of  young  infants,  with  the  object  of 
determining  the  differences  as  regards  the  number  and  character  of  the 
corpuscles  as  compared  with  adults.  The  results  of  various  observers  are 
in  some  cases  at  variance,  and  some  care  is  recjuired  in  drawing  conclusions. 
The  results  given  must  not  be  taken  as  being  universally  correct.  The 
nucleated  red  blood  corpuscles  found  during  the  early  months  of  intra-uterine 
life  are  only  very  exceptionally  to  be  seen  in  the  blood  of  the  newly  born 
when  born  at  full  time.  The  red  corpuscles  are  more  numerous  in  the 
newly  born  (5,000,000  to  6,000,000  per  cub.  mill.)  than  in  the  adult,  and  also 
vary  more  in  size  (Hayem).  In  a  few  weeks  this  disparity  in  numbers  dis- 
appears, the  number  of  corpuscles  falling  to  4,000,000-5,000,000.  The 
cjuantity  of  Hb  is  also  greater  in  the  newly  born,  but  falls  rapidly  during  the 
first  few  days  or  weeks  ;  it  is  lower  during  childhood  than  during  adult 
life  (Leichenstern).  The  leucocytes  are  also  both  relatively  and  absolutely 
more  numerous  ;  the  greater  number  are  of  the  small  mono-nuclear 
variety  (lymphocytes).  The  eosinophile  cells  are  also  increased  (Kanthack). 
The  amount  of  fibrin-formers  appears  to  be  less  as  coagulation  occurs  less 
completely.  The  amount  of  blood  in  the  body  is  relatively  less  than  in 
adults,  being  one-nineteenth  of  the  body  weight,  while  in  the  adult  it  is  one- 
thirteenth  (Welcker).  In  older  children  in  health  the  blood  does  not 
appear  to  materially  differ  from  the  blood  of  adults. 

Pulse. — At  the  end  of  foetal  life  the  number  of  cardiac  contractions  per 
minute  is  about  132  in  boys  and  140  in  girls  ;  in  the  newly  born  infant  it  has 
fallen  to  130  to  133.  According  to  some  observations,  the  pulse  rate  falls 
notably  immediately  after  the  ligature  of  the  cord,  to  regain  its  normal 
number  an  hour  or  two  later.  During  the  week  succeeding  birth  it  varies 
from  120  to  140,  crying  immediately  increasing  the  number  some  10  to  30 
beats.  By  the  second  year  it  has  fallen  to  no,  by  the  fifth  to  100,  by  the 
eighth  to  90,  and  by  the  twelfth  to  80. 

During  sleep  the  pulse  rate  is  diminished,  especially  in  infants,  some- 
times by  as  much  as  10  or  20  beats.  The  pulse  is  more  often  irregular 
in  infants  and  children  than  in  adults,  and  this  apart  from  the  influence  of 
disease. 

According  to  Soltmann  the  inhibitory  action  of  the  vagus  is  less  marked 
in  newly  born  animals  than  in  adults.  The  circulation  of  the  blood  in 
infants  and  children  is  carried  on  more  rapidly  than  in  adults,  and  conse- 
quently the  tissues  are  supplied  with  a  superabundance  of  arterial  blood. 
The  tension  in  the  arteries  is  comparatively  low,  on  account  of  the  relatively 
large  size  of  the  aorta  and  arterial  system  generally. 

According  to  Vierordt  a  complete  circulation  takes 

In  newly  born  infants  in  12  seconds  (134  pulse  rate) 
At  two  years         .         -15        „        (107        „ 
At  fourteen  years  .     i8-6    „        (  87         „ 

In  adults      .         .         .     22       „         (72         „  ) 


6  The  Physiology  of  Infancy  and  CJiildhood 

On  account  of  the  proneness  of  the  pulse  to  be  influenced  by  excitement 
during  infancy,  it  is  of  less  value  in  diagnosis  at  this  period  than  in  later  years. 

illiinentary  Canal. — For  the  first  six  to  eight  weeks  of  life  there  is  very 
slight  secretion  of  saliva,  only  sufficient  being  formed  to  render  the  mouth 
moist.  In  the  third  and  fourth  months  the  secretion  is  much  more  free,  so 
that  infants  about  this  period  begin  to  dribble  ;  the  amount  of  secretion  be- 
comes still  larger  as  the  period  of  dentition  approaches.  By  the  third  or 
fourth  month  the  saliva  contains  ptyalin,  and  readily  converts  cooked  starch 
into  maltose.  The  stomach  of  the  newly  born  infant  is  small,  its  capacity 
being  one  or  two  fluid  ounces,  by  the  end  of  the  fourth  week  from  three  to 
four  ounces,  at  three  months  about  five  ounces,  and  at  the  end  of  the  first 
year  ten  ounces.  The  muscular  layers  of  the  stomach  and  intestines  are  at 
first  only  slightly  developed,  hence  the  feebleness  of  the  peristaltic  action 
and  the  tendency  to  the  accumulation  of  gases  in  both  the  stomach  and 
bowels.  The  gastric  juice  has  at  first  but  imperfect  digestive  powers,  and 
the  stomach  is  in  consequence  quickly  exhausted  ;  the  peristaltic  action  of 
the  walls  of  the  stomach  is  often  very  vigorous,  and  may  give  rise  to  the 
regurgitation  of  the  food  swallowed,  especially  as  the  cardiac  sphincter  is 
weaker  and  more  easily  gives  way  in  infants  than  in  adults. 

The  part  which  the  stomach  plays  in  the  digestion  of  milk  during  infancy 
has  been  much  discussed.  To  what  extent  is  it  simply  a  reservoir  in  which 
curdling  takes  place,  digestion  being  performed  in  the  intestines  ?  Does 
it  perform  the  double  function  of  reservoir  and  play  an  important  part  in  the 
digestion  of  proteids  ?  Under  normal  circumstances  there  can  be  little 
doubt  that  some  of  the  curd  of  milk  is  converted  into  peptone  in  the  stomach, 
while  a  varying  amount  passes  on  into  the  intestines  unchanged.  Proteid 
digestion  is  continued  in  the  intestines  in  an  alkaline  medium,  and  a  certain 
portion  appears  to  escape  altogether,  and  is  passed  in  the  faeces.  Under 
abnormal  conditions,  as  when  the  infant  is  fed  on  cow's  milk,  or  is  overfed, 
by  far  the  major  part  of  the  curd  passes  out  of  the  stomach  unchanged,  to 
be  attacked  by  the  juices  of  the  intestines,  but  much  escapes  digestion,  and 
is  passed  per  rectum.  Both  the  juices  of  the  stomach  and  intestines  are 
easily  exhausted  by  overfeeding,  and  fermentative  changes  take  place,  and 
decomposition  products  are  formed  instead  of  peptones.  Coagulation  of 
milk  takes  place  in  the  stomach  through  the  agency  of  a  ferment  in  from 
lo  to  15  minutes,  which  is  independent  of  the  acid  or  pepsin.  Human  milk 
coagulates  in  fine  flocculi  ;  cow's  milk,  especially  if  undiluted,  in  heavy  dense 
masses.  In  young  infants  taking  human  milk  gastric  digestion  is  complete 
in  an  hour  and  a  half  or  thereabouts,  the  stomach  being  empty,  but  a  longer 
time  is  required  for  the  stomach  to  get  rid  of  a  meal  consisting  of  cow's 
milk.  Obser\'ations  have  shown  that  the  hydrochloric  acid  secreted  is 
absorbed  by  the  proteids,  and  it  is  only  towards  the  end  of  digestion,  when 
the  stomach  has  passed  on  most  of  its  contents,  that  free  acid  can  be  detected. 
Lactic  acid  does  not  appear  to  be  a  normal  constituent  of  digestion,  but  it  is 
common  enough  as  a  product  of  fermentation.  ^ 

For  the  first  few  months  the  diastatic  ferments  of  the  pancreatic  and 
intestinal  juices  are  exceedingly  feeble,  so  that  starches  are  not  digested, 

1  .See  Disorders  of  Digestion  in  Infancy  and  Childhood ,  by  W.  Soltau  Fcnwick,  A4.D. 


Alimentary  Canal — Urine  7 

while,  on  the  other  hand,  the  trypsin  of  these  secretions  is  active  from  tlic 
first.  The  secretion  of  bile  begins  at  an  early  period  of  foetal  life,  probably 
about  the  third  month  ;  the  bile  accumulates  in  the  small  intestines  and  is 
passed  as  the  meconium  during  the  first  few  days  after  birth.  It  forms  dark 
brown  or  greenish  masses,  viscous  and  tenacious,  and  of  a  feebly  acid  re- 
action, and  consists  of  mucus  holding  in  suspension  fatty  matters,  epithelial 
cells,  biliary  pigments,  and  cholesterine,  but  no  bile-acids.  Three  or  four 
days  after  birth  the  meconium  is  succeeded  by  the  golden  yellow  semi-liquid 
stools  characteristic  of  the  healthy  infant.  This  yellow  colour  is  due  to  the 
bili-rubin  of  the  bile  ;  the  green  colour  sometimes  seen  in  intestinal  catarrh 
depends  upon  the  oxidation  of  the  bili-rubin  and  formation  of  bili-verdin. 
Under  normal  circumstances  newly  born  infants  have  two  or  three  stools 
daily.  Their  character  gradually  changes  as  the  infants  get  older,  becoming 
more  and  more  like  the  stools  of  adults. 


Fig.   I. — Stomach  of  a  Newly  Born  Infant  (natural  size). 

ITrine. — The  newly  born  infant  generally  passes  water  within  24  hours 
of  its  birth,  and  continues  to  do  so  some  10  or  12  times  daily,  passing  about 
I  oz.  at  a  time,  or  about  10  oz.  in  24  hours.  The  first  urine  passed  is  cloudy 
from  the  presence  of  uric  acid  and  epithelial  cells,  and  is  of  specific  gravity 
1003-1006  ;  later  it  becomes  clear  and  of  a  light  straw  colour.  It  contains 
more  uric  acid  and  less  urea  (about  -5  per  cent.)  than  does  that  of  adults. 

During  the  whole  of  childhood  the  urine  is  of  a  paler  colour,  has  a  more 
decidedly  acid  reaction,  and  lower  specific  gravity  (1012-1015)  than  during 
adult  life  (1018-1020)  ;  smaller  quantities  are  also  passed,  but  on  account  of 
the  difficulty  of  collecting  the  total  quantity  the  amounts  have  not  been  ac- 
curately determined.     The  following  figures  may  be  taken  as  approximative  : 

Between  2-5  yrs.  about  15-25  oz.,  containing  5-14  grammes  of  urea  (in  24  hrs.) 

5-9    ..       ..        25-35    ,,            ,,  14-19 

..       9-14    ..       ..        35-40    ,,            ,,  19-22 

Adults          , ,             50    , ,           , ,  30          , ,           , , 

While  actually  smaller  cjuantities  of  urine  are  passed  by  children  than 
adults,  yet  relatively  the  amount  is  greater  ;    the  observations  of  Carriere 
and  Monfit '  have  shown  this  and  also  that  the  amount  of  solids,  total  N, 
1  Pressc  mMicale,  21  Juillet,  1897. 


8  TJie  Physiology  of  Infancy  and  Childhood 

and  urea  per  kilogramme  of  body  weight  is  more  during  childhood  than  in 
adult  life.  The  same  observers  found  the  amount  of  uric  acid  actually  and 
relatively  less  in  amount. 

The  amount  of  urea  excreted  per  kilogramme  of  body  weight  is  as 
follows  : 

15  mths.  to  5  yrs.     .      •61  grammes       \      10  yrs.  to  15  yrs.     .     -49  grammes 
5  yrs.     „  10  yrs.     .     -65        ,,  I      Adults -40         „ 

Temperature. — The  temperature  of  an  infant  at  birth  taken  in  the 
rectum  is  about  100°  F.  (3775°  C,  Roger,  Sommer).  A  few  minutes  after 
birth  it  sinks  to  97°,  or  in  weakly  infants  still  lower  ;  in  the  course  of  a  few- 
hours  it  again  rises  and  remains  at  about  98"8°  F.  This  temperature  or  a 
fraction  of  a  degree  higher — 98-8-99°  F. — may  be  taken  as  the  normal  rectal 
temperature  during  childhood  and  youth.  For  young  children,  if  exact 
observations  are  required,  the  rectum  is  the  best  place  to  insert  the  thermo- 
meter, as  it  is  difficult  to  keep  the  infant  quiet  with  a  thermometer  in  its 
axilla.  It  is  important  to  remember  that  the  rectal  temperature  exceeds 
that  of  the  axilla  by  about  7°  F.  For  most  clinical  observations  the  fold  of 
the  groin  or  the  axilla  may  be  taken.  What  is  also  of  importance  is  the  time 
at  which  it  is  taken.  According  to  the  careful  researches  of  Finlayson,  the 
diurnal  range  of  temperature  amounts  to  about  2°  F.,  the  maximum  being 
at  5  to  6  P.M.  and  the  minimum  in  the  small  hours  of  the  morning  ;  the  range 
of  temperature  in  adults  being  somewhat  less.  According  to  Reitz,  the  lowest 
temperature  is  between  4  and  5  a.m.,  increasing  to  11  a.m.,  falling  to  2  p.ivr., 
then  rising  to  its  diurnal  maximum  at  6  P.M. 

The  most  recent  observations  upon  the  temperature  of  children  in  health 
were  made  by  the  late  Dr.  O.  Sturges.  The  most  interesting  of  these  were 
made  upon  two  sturdy  children  living  in  the  country,  aged  respectively  i  year 
and  2  years.  The  temperatures  were  taken  at  various  hours  from  10  a.m.  to 
midnight,  the  usual  range  being  97-4  to  98*6.  The  highest  temperature  was 
after  breakfast,  when  the  children  were  most  lively  and  eager  for  play. 

The  heat  of  the  body  is  maintained  with  greater  difficulty  during  infancy 
than  in  later  life,  a  result  due  not  only  to  the  relatively  larger  surface,  but 
also  to  the  much  greater  vascularity  of  an  infant's  skin.  Infants  and  children 
are  much  more  liable  to  suffer  from  cold  extremities  than  are  adults. 

Uervous  System. — The  closure  of  the  anterior  fontanelle  takes  place  to- 
wards the  end  of  the  second  year  in  strong  and  vigorous  children  ;  in  immature 
and  rickety  children  it  may  be  delayed  till  the  third  year,  or  it  may  be  later. 

The  circumference  of  the  head  averages  at  : 

Birth 14  inches       I  2  years 20  inches 

6  months     ....     16^     „  I  4    „ 21       „ 

12        „  ....      18       „  I         10     „ 2li     „ 

The  cubic  capacity  of  the  skull  in  newly  born  infants  is  about  one-third 
that  of  adults,  viz.  500  c.c.  ;  by  the  second  year  it  is  about  1,000  c.c,  while 
in  the  adult  it  is  about  1,500  c.c.  The  brain  of  a  newly  born  infant  forms 
about  14  per  cent,  of  its  body  weight,  while  in  the  adult  it  is  only  2-37  per 
cent.  The  brain  doubles  its  weight  during  the  first  year  of  life— 14  oz.  to 
28  oz. — by  the  seventh  year  it  has  reached  38  oz.  ;  by  the  fourteenth  or 
fifteenth  year  42  oz.  to  45  oz.  ;  the  average  brain  weight  of  an  adult  (male) 


Nervous  System — Sight — Hearuig  g 

being  about  50  oz.  The  cerebellum  after  birth  develops  more  quickly  than 
other  parts  of  the  brain,  the  frontal  lobes  more  slowly  till  six  years  of  age, 
when  they  develop  rapidly. 

If  the  brain  of  a  newly  born  infant  be  examined,  it  will  be  noted  that  its 
consistence  is  much  less  firm  than  is  that  of  an  adult's,  and  it  is  much  more 
readily  injured.  If  placed  on  a  plate  it  spreads  itself  out  or  moulds  itself 
into  any  shape  more  readily  than  an  adult's  brain.  The  pia  mater  is  ex- 
ceedingly delicate  and  very  easily  dissected  off  with  a  pair  of  forceps.  In 
colour  the  brain  is  light  grey,  often  yellowish  from  the  presence  of  bile  pig- 
ments ;  there  is  no  well-marked  difference  between  the  '  grey '  and  '  white ' 
substance  as  in  adult  brain,  and  the  convolutions  are  less  distinctly  marked. 
The  multipolar  cells  in  the  grey  matter  on  the  surface  are  ill  developed,  as 
also  is  the  pyramidal  bundles  of  nerves  which  connect  them  with  the  basal 
ganglia  and  internal  capsule  ;  on  the  contrary,  the  nerve  elements  of  the 
cord  and  spinal  nerves  are  well  developed. 

From  the  above  facts  it  is  clear  that  while  the  excito-motor  centres  in  the 
spinal  cord  and  medulla  are  well  developed  at  birth,  the  higher  centres — the 
'  think-organs ' — on  the  surface  of  the  brain  are  imperfect,  and  so  also  are  the 
strands  or  nerve-paths  which  connect  the  higher  and  lower  centres.  This 
agrees  also  with  the  experiments  of  Soltmann,  who  has  shown  experi- 
mentally that  the  application  of  some  form  of  irritation,  as  the  induced 
current,  to  the  surface  of  the  brains  of  newly  born  animals  does  not  evoke 
movements  in  the  face  and  limbs  as  it  does  in  adults.  The  actions  of  infants 
— sucking — crying — swallowing — breathing — are  reflex,  and  inasmuch  as 
they  are  uncontrolled  by  the  inhibitory  influence  of  the  higher  centres,  are 
apt  to  be  disorderly  and  excessive  ;  as,  for  instance,  in  convulsions.  The 
reflex  actions  displayed  by  a  brainless  frog  are  more  violent  and  vigorous 
than  those  displayed  when  the  brain  is  intact.  The  readiness  with  which 
the  newly  born  infants  become  convulsed  is  one  of  the  most  remarkable  fea- 
tures in  early  life.  Hereditary  influences  play  an  important  part,  infants 
coming  of  a  neurotic  stock  being  much  more  prone  to  convulsions  from 
slight  exciting  causes  than  others.  As  the  higher  centres  develop,  changes 
come  over  the  mental  character  of  the  infant,  and  the  reflex  actions  become 
more  and  more  under  control  and  dominated  by  the  psychical  centres.  The 
movements  of  newly  born  infants  are  almost  entirely  reflex,  though  certain 
'  spontaneous '  or  '  impulsive  '  movements,  such  as  stretching  the  limbs,  occur. 

Sig^lit. — In  the  first  week  after  bir'ih  the  infant  apparently  cannot  distin- 
guish objects,  but  can  light  from  darkness.  According  to  Preyer's  examina- 
tions, the  movements  of  the  eyes  are  not  co-ordinated  at  first.  Konigstein, 
from  an  examination  of  300  newly  born  infants,  states  that  they  were  all 
hypermetropic.  The  colour  of  the  iris  is  bluish-grey  or  green,  but  one  finds 
also  shades  of  light  grey  and  brown.  The  same  investigator  has  also  noted 
blood  extravasations  in  the  retina,  which  disappear  in  a  few  days.  The  pupils 
are  very  large  in  the  newly  born,  and  sensitive  to  light  ;  in  later  child- 
hood they  can  endure  strong  light  better  than  can  adults.  Of  the  colours, 
children  learn  first  to  distinguish  white  from  black  ;  in  the  second  year  they 
learn  to  distinguish  other  colours,  first  red  and  yellow,  later  green  and  blue. 

Hearing-. — In  the  newly  born  the  mucous  membrane  of  the  tympanum  is 
swollen  so  that  no  cavity  is  present,  consequently  they  are  not  very  sensitive 


10 


TJie  Physiology  of  Infancy  and  Childhood 


to  sounds,  but  shrill  and  strong  sounds  make  impression,  the  infants  waking 
with  cries.  In  the  first  months  children  hear  high  and  sharp  sounds  better 
than  deep.  Older  children  can  hear  very  weak  and  high  sounds  which 
make  no  impression  on  adults. 

Taste. — Newly  born  infants  can  distinguish  sweet,  bitter,  sour,  and  salt 
tastes. 

Psychical  Phenomena. — In  the  second  month  an  infant  learns  to  hold 
up  its  head  and  make  voluntary  movements  and  to  distinguish  the  voices  of 
Its  friends.  At  the  3rd  or  4th  week  it  can  laugh,  and  smiles  when  caressed. 
In  the  3rd  to  4th  month  the  infant  notices  its  toys  or  anything  it  can  hold  in 
its  hands,  mostly  putting  them  to  its  mouth.  At  7  to  9  months  the  child  can 
sit  up,  and  3  or  4  months  later  makes  attempts  to  walk  ;  when  a  year  old 
well-developed  children  can  walk  a  few  steps  without  help.  From  this  time 
the  child  begins  to  say  a  few  syllables,  such  as  td-td^  dd-dd,  be-be^  without 
much  notion  of  applying  them  ;  then  words  are  learnt,  and  by  the  end  of 
the  second  year  most  children  can  string  a  few  words  together.^ 

Sleep. — The  newly  born  infant  sleeps  all  day  except  when  it  wakes  up 
for  food.  At  a  year  old  the  infant  sleeps  fifteen  to  sixteen  hours  ;  from  2  to  3 
years,  twelve  to  thirteen  hours  ;  from  4  to  5  years,  no  sleep  in  the  day, 
from  ten  to  twelve  hours  at  night ;  from  12  to  13  years,  eight  to  nine  hours. 
Infants  sleep  lightly  and  are  easily  awakened  ;  at  4  to  5  years  of  age  they 
are  generally  heavy  sleepers. 

Body  Weig^bt. — An  infant  born  at  full  term  weighs  from  b^  to  ']\  lb., 
7  lb.  being  an  average  weight.  For  the  first  two  or  three  days  of  life  there 
is  a  loss  of  4  oz.  to  7  oz.,  then  a  regular  gain,  so  that  by  the  8th  or  gth  day 
the  initial  loss  has  been  made  good.  According  to  Gregory,  the  following 
figures  express  the  average  daily  loss  and  gain  during  the  first  six  days  of  life  : 


2f 


1st  day     . 

.     loss  of  13c 

2nd  „       . 

•     „    64 

3id    „ 

.    gain  of  33 

4th    „ 

50 

5th    „        . 

50 

6th    „        . 

„        36 

about  I 


That  these  figures  are  by  no  means  universally  correct  is  clear  from  the 
difference  in  weight  noted  by  different  observers  ;  thus,  according  to  Lewis 
Smith,  in  170  infants  born  in  the  New  York  Infant  Asylum  (89  male  and  81 
female),  the  average  weight  of  the  boys  was  7  lb.  11  oz.  and  the  girls  7  lb. 
4  oz.  Fifty  of  these  were  v/et-nursed,  and  weighed  when  one  week  old,  with 
the  following  result : 


Increase  of  weight  in 
Loss     . 
Average  gain 
,,         loss 
Greatest  gain 
loss 


32  cases 

13      » 
4-8  oz. 

yi  „ 
12    „ 


1   For  an  account  of  the  developnient  of  the  .nfant's  mind,  see  Health  iti  the  Nursery, 
Lons^mans  &  Co. 


Body    Weight 


II 


Growth  during  the  first  year,  more  especially  during  the  first  six  months, 
is  extremely  rapid,  the  infant  doubHng  its  weight  in  the  first  six  months  and 
trebhng  it  during  the  first  year.  Many  observations  have  been  made  on  the 
weights  of  children  during  the  first  year  ;  the  following  table  exhibits  the 
monthly  gains,  being  the  average  of  nine  infants  observed  by  W.  Pfeiffer,  who 
were  nursed  at  the  breast  at  first,  and  later  this  was  supplemented  with  cow's 
milk  : 

Age.  Monthly  gai/j.      Weight  at  end  of  the  mo7iths. 


1st  month 

2nd  ,, 

3i'd  „ 

4th  „ 

5th  „ 

6th  „ 

7th  „ 

8th  „ 

9th  „ 

loth  „ 

1 1  th  „ 

1 2th  „ 


•3t 

30^ 

26^ 

26' 

21 

21 

17 
21 
23 
20^ 
II 
7 


8 

5A 

10 

4 

1 1 

15 

13 

9i 

14 

I4i 

16 

1I 

J2 

17 

5 

18 

10 

20 

I 

21 

5i 

22 

0 

22 

7 

MANCHESTER 

CHILDREN'S  HOSPITAL. 

lbs. 


Name- 


Date  of  Birth 

Weight  at  Birth 

Notes  of  Food,  &^<;.- 


26 


CHART    TO    SHOW    INCREASE     IN    WEIGHT    DURING    THE    FIRST    YEAR. 

AGE    IN   WEEKS. 


1 

12 

16 

20         24           28          32          36         40          44         48          52 

y 

^ 

-                                                                ^  c 

^^-_      _    __ 

" 

^^ 

\ 

~ 

- 

^i__          -      _     _ 

y'' 

^ 

-  _^^              _       .  _   _  __ 

;=' 

^^ 

^^ 

..- 

^-  ' 

^'' 

.._. 

- 

- 

- 

^: 

^ 

.,  -- 

__ 

J 

u 

_ 

. 

_. 

DOTTED    LINE    SHOWS  AVERAGE    WEIGHT    AT    DIFFERENT    AGES. 


Fig.  2. — Weight  Chart,  showing  normal  weights  during  first  year.     The  infant's  weight 
can  be  filled  in  with  ink  or  pencil  every  week.     (Reduced  size.) 


12 


TJie  Physiology  of  Infancy  and  Childhood 


Growth  after  the  end  of  the  first  year  is  slower,  so  that  the  weight  is  not 
again  doubled  till  the  end  of  the  sixth  year,  and  doubled  again  by  the  end  of 
the  fourteenth. 

During  health  it  will  be  often  enough  to  weigh  the  infant  once  a  week. 
It  is  con'/enient  to  record  the  weight  on  a  chart  such  as  the  one  figured 
(fig.  2)  ;  the  chart  can  be  fitted  into  a  case  and  hung  up  in  the  nursery. 

Much  interest  and  importance  is  attached  to  the  increase  of  weight  and 
height  during  infancy  and  childhood  :  weekly  weighings,  especially  during 
the  early  months  of  life,  give  very  valuable  information  with  regard  to  diet. 
It  must,  however,  be  always  borne  in  mind  that  increase  in  weight,  especially 
if  it  be  due  to  an  accumulation  of  fat,  does  not  always  indicate  strength,  or 
that  the  food  being  taken  is  a  suitable  one.  During  childhood,  undergrowth 
or  loss  of  weight  must  be  looked  upon  as  an  indication  of  danger  and  as  evi- 
dence of  malnutrition.  On  the  other  hand,  overgrowth  without  a  proportionate 
increase  in  weight  should  always  be  taken  as  indicative  of  weakness. 


Fig.  3. — Jaw  of  a  Child  at  Birth,  showing  the  Dental  Sacs  (Quain's  'Anatomy  ').  a,  the 
left  half  seen  from  the  inner  side  ;  b,  the  right  half  seen  from  the  outer  side ;  the  bone 
has  in  part  been  removed  to  expose  the  dental  sacs,  b  shows  the  sacs  of  the  temporary 
set  and  the  sac  of  the  first  permanent  molar  behind  the  posterior  molar  of  the  milk  set. 
a  shows  the  same,  and  also  the  sacs  of  the  permanent  incisors  and  canine. 

It  is  not  only  of  interest,  but  it  is  important,  to  both  weigh  and  measure 
children  at  frequent  intervals.  Periods  of  under  or  over  growth  are  periods 
of  danger,  as  indicating  either  malnutrition  or  an  overtaxing  of  the  strength. 
There  should  also  be  maintained  a  close  relation  of  height  to  weight. 

Dentition. — At  birth  the  jaw  contains  the  dental  sacs  with  the  already 
calcified  crowns  of  the  temporary  teeth.  Besides  the  temporary  teeth,  there 
is  the  calcified  crown  of  one  of  the  permanent  set,  the  first  molar,  which  is 
situated  immediately  behind  the  last  temporary  molar.     (See  fig.  3.) 

During  the  interval  which  elapses  between  birth  and  their  eruption,  the 
teeth  are  undergoing  further  development  ;  the  sacs  become  enlarged,  so  that 
they  are  readily  felt  through  the  gum  as  rounded  swellings,  the  edges  of  the 
teeth  become  sharper,  and  the  fangs  are  developed.     As  the  fangs  elongate, 


Dentition 


13 


the  edge  of  the  tooth  comes  nearer  to  the  surface  of  the  gum,  the  latter  swells 
and  becomes  more  vascular,  the  edge  of  the  tooth  appears  as  a  line  or  point 
l)eneath  the  membrane,  which  finally  becomes  perforated,  and  the  tooth  is  cut. 

The  temporary  set  appear  for  the  most  part  in  groups  in  the  following 
order.  First  group — The  lower  two  central  incisors  appear  from  the  6th  8th 
month,  followed  by  a  pause  of  from  three  to  six  weeks.  Second  group — The 
four  upper  incisors  are  cut  at  intervals  of  a  week  or  two,  from  the  8th-ioth 
month,  followed  by  an  interval  of  one  to  three  months.  Tbird  group — The 
lower  lateral  incisors,  the  upper  and  lower  front  molars  appear  at  intervals 
from  the  r2th-i4th  months,  followed  by  a  pause  of  two  or  three  months. 
Fourtb  group — The  canines  appear,  the  upper  ones  usually  being  first,  from 
the  i8th-20th  month.  Fifth  group — The  posterior  molars  mostly  appear 
at  the  age  of  2-2\  years. 

The  milk  set,  when  complete,  remain  unchanged  for  several  years,  though 
the  permanent  set  are  gradually  becoming  developed  in  their  sacs,  ready  to 
replace  the  earlier  set. 


Fig.  4.  -  Lower  Jaw  of  a  Child  of  about  three  years,  showing  the  relation  of  the  temporary 
and  permanent  teeth.  The  milk  teeth  of  the  right  side  and  incisors  of  the  left  are  .shown, 
and  also  the  sacs  of  the  permanent  set,  except  the  wisdom  tooth,  which  is  not  yet  formed. 
The  large  sac  near  the  ramus  of  the  jaw  is  that  of  the  first  permanent  molar,  and  above 
and  behind  it  is  the  rudiment  of  the  second  molar.     (Quain's  '  Anatomy.') 


The  following  formula  exhibits  the   relation  between  the  temporary  and 
permanent  set  : 

mo.  ca.    in.     in.    ca.    mo. 
(Upper  2       I       2    j    2       I       2  =10) 

Temporary  set-' -20 

(  Lower  2       i       2    I    2       i       2  =10) 


Permanent  set 


mo.     bi.     ca.     in.     in.     ca.     bi.    mo. 
Upper      3        2       I       2    I    2       I       2       3=16; 


Lower 


3=  16, 


At  six  years  of  age  there  are  a  greater  number  of  teeth  in  the  jaws  than 
at  any  age,  there  being  the  milk  set  and  all  the  permanent  set  except  the 
wisdom  teeth. 

It  is  to  be  particularly  noted  that  during  this  period  a  marked  increase 


14  The  Physiology  of  Infancy  and  Childhood 

takes  place  in  the  length  of  the  jaw  to  provide  room  for  the  three  molars  of 
the  permanent  set,  which  make  their  appearance  posteriorly  to  the  milk  set  ; 
the  ioicuspids  replace  the  temporary  molars  (see  fig.  4). 

While  the  above  account  represents  the  state  of  things  which  obtains 
under  normal  conditions,  yet  important  deviations  both  as  to  the  time  of  the 
appearance  of  the  teeth  through  the  gum  and  the  condition  of  the  teeth 
themselves  frequently  take  place  as  the  result  of  disease  or  enfeebled  nutri- 
tion. It  is  well  known  that  rickets  is  the  most  common  cause  of  delayed 
dentition,  and  not  only  are  the  teeth  cut  later  than  usual,  but  the  defective 
nutrition  which  exists  in  this  state  frequently  interferes  with  the  develop- 
ment of  the  teeth  ;  they  may  in  consequence  be  dwarfed  or  provided  with  a 
thin  or  partially  deficient  layer  of  enamel,  so  that  they  quickly  become  carious 
after  being  cut. 

The  jaw  of  the  infant  at  birth  contains  the  calcified  crowns  of  all  the  milk 
teeth  and  also  the  calcified  crown  of  one  of  the  permanent  set,  namely,  the 
first  or  '  six-year-old '  molar,  which  commences  to  calcify  during  the  sixth 
month  of  intra-uterine  life.  The  calcification  of  the  permanent  incisors 
commences  when  the  infant  is  about  a  month  old,  the  canines  at  3  or  4 
months  of  age  and  the  bicuspids  later,  in  the  first  or  second  year.  The 
crown  of  the  second  permanent  molar  begins  to  calcify  during  the  fourth  or 
fifth  year,  but  the  wisdom  tooth  not  till  about  puberty. 

It  is  plain,  therefore,  that  any  illness  occurring  during  the  first  year,  such 
as  syphilis,  can  only  affect  the  calcification  of  the  incisors,  canines,  and 
possibly  the  bicuspids.     (See  SECOND  Dentition,  p.  63.) 

The  permanent  teeth  are  cut  in  the  following  order  : 

6  years  of  age 


iViUldl,   111  3U 

Incisors,  central 

7 

„         lateral 

8 

Bicuspid,  anterior 

9 

„           posterior 

10 

Canines     . 

.   11-12 

Molars,  second 

•   12-13 

„     third     . 

•   17-25 

IVXortality  in  Infancy  and  Cbildhood. —  In  this  country,  out  of  every 
1,000  children  born,  on  an  average  149  die  before  the  end  of  their  first  year 
of  life,  and  263  before  the  age  of  5  years.  During  the  next  five  years,  from 
5  to  10  years  of  age,  35  die,  and  18  more  between  the  ages  of  10  and  15 
years.  So  that  out  of  the  original  1,000,  684  will  be  alive  on  their  fifteenth 
birthday  and  316  will  be  dead.  From  these  figures  it  is  clear  that  the 
mortality  is  the  greatest  during  the  first  year,  and  that  it  rapidly  declines  as 
childhood  advances.  Indeed,  the  mortality  is  the  greatest  during  the  first 
day  and  succeeding  days  after  birth  ;  thus  Korosi,  in  analysing  the  ages  of 
infants  at  death,  found,  out  of  26,623  infants  born  in  Pesth  during  the 
years  1874  and  1875,  that  out  of  every  1,000  born,  13  died  within  24  hours  ; 
57  on  the  second  day  ;  34*2  during  the  first  week  ;  26-3  during  the  second 
week  ;  and  92  during  the  first  month. 

It  appears  that  infant  mortality  is  slowly  decreasing  in  this  country, 
though  at  a  much  slower  rate  than  adult  mortality.     Thus  in  England  and 


Mortality  in  Infancy  and  Childhood  15 

Wales  the  mortality  during  the  decades  185 1  60  and  1861-70  was  equal  to 
154  per  1,000.  In  the  years  1871-80  it  declined  to  149,  while  in  i88r  90 
it  was  142. 

The  mortality  of  infants  differs  enormously,  and  is  dependent  upon  the 
amount  of  care  which  is  taken  in  their  feeding,  and  the  way  in  which  they 
are  looked  after,  as  well  as  upon  their  parentage.  Roughly  speaking,  it  may 
be  said  that  among  the  rural  population  of  Great  Britain,  and  among  the  well- 
to-do  dwellers  of  suburban  districts,  the  annual  infant  mortality  amounts  to 
100  per  1,000,  900  out  of  every  1,000  children  born  being  alive  at  the  end  of 
the  first  year.  This  is  the  average  infantile  death  rate  of  Norway,  which  is 
the  lowest  of  any  European  country,  and,  indeed,  probably  in  the  world. 

In  a  large  city,  such  as  Manchester  or  Liverpool,  the  annual  death  rate 
among  infants  under  a  year  is  200  per  1,000  births,  or,  in  other  words,  one- 
fifth  of  those  born  never  reach  the  end  of  their  first  year.  In  the  worst  and 
most  crowded  districts  there  is  little  doubt  that  the  mortality  is  at  least  300 
per  1,000,  one-third  of  those  born  never  living  to  become  a  year  old.  A  still 
higher  death  rate  prevails  among  the  unfortunate  class  of  illegitimate  chil- 
dren ;  the  mortality  among  these  amounts  at  times  in  some  districts  of  our 
large  cities  to  500  per  1,000,  not  more  than  half  living  to  be  a  year  old.  In- 
deed, the  mortality  has  in  some  districts  of  Salford  risen  to  710  per  1,000.' 

In  London  the  rate  of  infant  mortality  is  about  the  same  as  that  of  the 
country  generally,  namely,  150  per  1,000.  The  mortality  is  the  same  in 
Paris  as  in  London,  while  in  most  Continental  cities  it  is  higher.  In 
Munich  (1884-1889)  it  averaged  324  per  1,000  ;  in  Berlin,  268  per  1,000  ;  in 
Russia,  266  ;  and  in  Austria,  255  (Rahts). 

As  one  would  naturally  expect,  child  mortality  also  differs  greatly  under 
different  circumstances  ;  thus  we  find  in  the  health)^  parts  of  England  the 
annual  mortality  of  children  under  five  years  of  age  is  not  more  than  50  per 
1,000  (living  at  that  age),  that  is,  out  of  every  20  children  (under  five  years 
of  age)  only  one  will  die  during  the  year  ;  whilst  in  the  worst  districts  100 
or  even  no  per  1,000  perish  annually. 

Child  mortality  is  also  slowly  decreasing  in  this  country.  During  the 
ten  years  1861-70  the  mean  annual  death  rate  of  children  under  five  years 
of  age  was  ec]ual  to  68-6  per  1,000.  During  1871-80  it  fell  to  63-5  per  1,000  ; 
while  in  1881-90  it  fell  to  56-8  per  1,000.  This,  however,  is  just  twice  the 
mortality  given  by  Ansell's  tables,  which  are  based  on  the  experience  of 
child  life  among  the  upper  classes,  namely,  28-2. 

Of  the  causes  of  death  in  these  cases,  it  may  be  taken  for  granted  that 
diseases  of  the  digestive  system  play  a  most  important  role  ;  but  statistics 
are  more  or  less  untrustworthy,  as  the  causes  of  death  which  appear  on  death 
certificates  are  often  not  to  be  relied  upon  for  purposes  of  classification. 
Analysing  the  causes  of  death  from  2,000  cases  of  infants  under  two  years 
of  age,  who  died  while  under  the  care  of  the  medical  officers  of  our  own 
Children's  Dispensary,  we  found  that  of  the  fatal  cases  those  connected  with 
the  digestive  system  head  the  list,  forming  35  per  cent,  of  the  total  number. 
Bronchitis  and  its  allies  caused  death  in  21  per  cent,  of  the  cases  ;  whooping- 
cough  in  12  per  cent.  ;  congenital  syphilis  in  10  per  cent.  ;  and  measles  in 
9  per  cent. 

1   See  Dr.  John  Tatham's  Health  Rep07'ts  for  Salford. 


1 6  TJie  Physiology  of  Infancy  and  Childhood 

Among  the  less  frequent  causes  of  death  we  find  tuberculosis,  meningitis, 
diphtheria,  and  various  malformations.  We  must  not  forget  to  mention  that 
premature  birth  accounts  for  some  deaths  that  do  not  figure  in  our  list,  and 
those  unfortunately  too  common  cases  which  are  returned  as  '  found  dead 
in  bed.' 

Infant  mortality  should  not  be  calculated,  as  is  sometimes  done,  by  com- 
paring infant  deaths  with  deaths  at  all  ages,  or  with  the  number  of  persons 
living,  inasmuch  as  in  a  given  population  there  may  be  many  or  few  children 
or  few  old  people,  but  it  should  be  calculated  on  the  infant  population,  or 
the  number  of  children  living  at  that  age.  Thus  the  number  of  deaths  in 
infants  under  a  year  old  should  be  compared  with  the  number  of  infants 
living  at  the  time,  which  is  usually  calculated  as  the  mean  of  the  births 
in  that  and  the  preceding  year.  In  the  same  way  the  mortality  of  children 
under  five  years  is  calculated  by  comparing  the  deaths  in  the  year  with  the 
number  of  children  living  under  five  j^ears  of  age. 


17 


CHAPTER     II 

THE     DISEASES    INCIDENT    TO    BIRTH 

There  are  certain  lesions  which  can  occur  only  once  in  a  lifetime,  inasmuch 
as  they  owe  their  origin  to  the  act  of  birth,  or  to  those  important  changes 
which  occur  in  the  life  conditions  of  the  infant  when  it  exchanges  the  quiet 
dependence  of  intra-uterine  life  for  the  greater  activity  of  an  independent 
existence.  Though  many  of  these  morbid  conditions  differ  from  one  another 
in  various  ways,  yet  they  are  so  intimately  associated  in  their  pathology  and 
etiology  that  it  is  most  convenient  to  discuss  them  together,  rather  than  to 
relegate  them,  as  is  often  done,  to  their  respective  places  in  the  ordinary 
classification  of  disease.  The  act  of  birth  brings  its  own  special  dangers  to 
the  infant  as  well  as  to  the  mother,  and  it  is  hardly  surprising  to  find  that 
many  perish  on  the  threshold  of  life,  and  that  the  mortality  during  the  first 
few  days  afier  birth  is  greater  than  that  of  any  other  period.  It  must  also  be 
borne  in  mind  that  parturition  is  not  only  responsible  for  many  infant  deaths, 
but  for  damage  done  to  the  nervous  centres  by  pressure  or  heemorrhage, 
which  may  be  irreparable,  and  if  the  infant  lives  it  is  paralysed  for  life  or  a 
hopeless  imbecile.  These  diseases  which  are  connected  with  parturition 
are  also  of  much  interest  and  importance,  in  that  many  of  them  are  eminently 
preventible,  and  are  often  the  result  of  the  ignorance  of  the  friends  or  neigh- 
bours, who,  in  the  absence  of  a  medical  practitioner  or  trained  nurse,  preside 
in  the  lying-in  room,  or  may  possibly  be  the  result  of 'meddlesome  mid- 
wifery.' However  this  may  be,  many  a  life  is  lost  and  various  morbid  con- 
ditions arise  for  want  of  assistance  during  the  later  stages  of  labour,  or  for 
the  want  of  care  and  cleanliness,  or  from  exposure  to  contagion  during  the 
first  few  days  which  succeed  birth.  We  will  first  consider  the  effects  of 
asphyxia,  so  common  in  nevv'ly  born  infants. 

Aspbyxia  Neonatorum. — It  is  hardly  to  be  expected  that  the  transition 
from  placental  to  pulmonary  respiration  should  be  accomplished  without  some 
risk  of  the  cessation  of  the  one  before  the  commencement  of  the  other. 
Fortunately  for  the  infant,  as  we  have  already  remarked,  its  nervous  centres 
and  tissues  generally  are  far  more  tolerant  of  a  venous  condition  of  blood  than 
they  are  in  after  life,  for  during  intra-uterine  life  the  aeration  of  the  blood  is 
far  less  perfectly  performed  by  the  placenta  than  it  is  afterwards  by  the  lungs, 
and,  moreover,  there  is  a  mixture  of  the  placental  blood  with  the  venous 
blood  of  the  inferior  vena  cava  before  it  is  distributed  to  the  body,  (a)  The 
infant  may  die  from  this  cause  before  birth,  or  it  may  be  born  asphyxiated  ; 
{b)  asphyxia  may  supervene  after  birth  through  failure  of  the  pulmonary 
respiration. 

C 


1 8  The  Diseases  incident  to  Birth 

{a)  x^sphyxia  before  birth  is  caused  by  the  death  or  faintness  of  the 
mother,  detachment  of  or  interference  with  the  placental  circulation,  or 
compression  of  the  cord.  Asphyxia  of  the  foetus  may  be  suspected  if  the 
foetal  heart  becomes  faint,  the  pulsation  of  the  cord  ceases  or  is  weak,  or  if 
meconium  is  passed.  In  infants  born  asphyxiated  the  symptoms  vary 
according  to  the  degree  of  asphyxia  present  ;  when  slight,  the  lips  are  of  a 
bluish  tint,  the  skin  dusky,  the  conjunctivae  injected,  the  limbs  are  motion- 
less, but  the  muscular  tonus  is  present,  the  heart's  action  is  slow  and  mostly 
visible,  the  movements  of  respiration  are  separated  by  long  intervals,  or  no 
attempts  are  made  unless  some  strong  reflex  irritation  is  applied.  In  the 
deeper  stages  of  asphyxia  the  face  and  lips  are  pallid,  the  extremities  blue, 
the  muscles  of  the  limbs  and  neck  have  lost  their  tonus,  no  attempts  are 
made  at  respiratory  movements,  or  only  a  few  inspiratory  efforts  accom- 
panied by  indrawing  of  the  ribs  and  epigastrium,  but  without  any  effect  in 
>expanding  the  lungs. 

{b)  Asphyxia  after  birth  is  in  rare  cases  the  result  of  a  haemorrhage  into 
t'he  fourth  ventricle  or  medulla,  and  thus  the  respiratory  centres  are  paralysed 
(Horrocks).  In  others,  mucus  or  liquor  amnii  has  been  sucked  into  the  air 
passages  during  the  act  of  birth,  or  a  heemorrhage  has  taken  place  into  the 
lungs  through  pressure  (Spencer).  Among  the  rare  causes,  asphyxia  maybe 
due  to  an  imperfect  development  of  the  diaphragm,  double  pleuritic  effusion, 
syphilitic  infiltration  of  the  lungs,  and  pressure  on  the  trachea  from  enlarged 
glands.  The  commonest  cause,  however,  is  weakness  or  immaturity  of  the 
infant;  its  ribs  are  wanting  in  rigidity  and  its  inspiratory  forces  feeble,  so 
that  it  fails  to  draw  in  air  with  sufficient  power  to  inflate  the  lungs  ;  as  a 
consecjuence  the  lungs  remain  to  the  greater  part  of  their  extent  in  the  foetal 
or  unexpanded  state,  a  condition  to  which  the  term  '  atelectasis '  is  apphed. 
Those  infants  who  have  some  complete  physical  obstruction  to  the  entrance 
of  air  into  the  lungs  necessarily  only  survive  their  birth  a  few  minutes  ; 
either  no  attempt  at  respiration  is  made  or  inspiratory  efforts  are  accom- 
panied by  recession  of  the  chest  walls,  without  any  air  entering  the  chest. 
Premature  or  weakly  infants  may  survive  for  many  hours  or  even  days  with 
a  large  portion  of  their  lungs  in  an  unexpanded  state.  They  are  extremely 
feeble,  their  cry  is  weak  and  whimpering,  their  lips  and  limbs  are  dusky 
blue,  and  their  temperature  below  normal.  Their  respiratory  movements 
are  confined  to  slight  contractions  of  the  diaphragm,  sometimes  accompanied 
by  indrawing  of  the  walls  of  the  chest  ;  they  have  hai'dly  strength  to  suck, 
and  are  in  a  drowsy  or  semi-comatose  condition.  They  frequently  suffer 
from  local  twitchings,  less  often  general  convulsions.  If  they  live  over 
forty-eight  hours  they  become  jaundiced  and  the  limbs  oedematous.  An 
examination  of  the  bodies  of  such  infants  reveals  the  usual  signs  of  death  from 
asphyxia  :  the  blood  is  dark  and  fluid  ;  the  right  heart  and  veins  distended  ; 
the  sinuses  and  membranes  of  the  brain  congested  and  a  meningeal 
haemorrhage  may  be  present.  The  lungs  will  be  found  in  a  condition  of 
atelectasis  or  pulmonary  apoplexy.  In  a  case  which  we  recently  examined 
in  which  the  infant  died  six  hours  after  birth,  both  lungs  sank  in  water,  were 
solid  everywhere  except  at  the  anterior  edges,  where  there  were  clusters  of 
air-containing  lobules  of  a  light  red  colour,  scattered  over  the  surfaces  of  the 
.upper  lobe.     The  cut  sections  displayed  purple  solid  lung  without  a  trace  of 


Asphyxia   Neonatorum  19 

expanded  lobules,  a  condition  due  probably  to  a  pulmonary  apoplexy  occur- 
ring during  birth.  In  another  case,  where  the  infant  lived  three  days,  the 
lungs  and  heart  together  just  floated  in  water,  but  the  lungs  everywhere  had 
a  solid  feel,  crepitating  very  slightly  ;  the  surfaces  of  both  lungs  were  covered 
with  distended  lobuies,  while  the  central  parts  were  solid.  As  a  rule, 
the  upper  lobes  are  more  often  expanded  than  the  bases,  and  the  anterior 
and  inferior  edges  and  surfaces  more  than  the  central  parts.  Care  must  be 
taken  not  to  confound  atelectasis  of  the  lung  with  pneumonic  consolidation  ; 
the  latter  condition  is  rare  in  the  newly  born. 

Treatine?tt. —  i.  Remove  any  mucus  or  fluid  from  the  fauces  and  air- 
passages  by  means  of  the  finger  or  by  suction  with  a  soft  india-rubber  catheter 
Inverting  the  body  may  be  useful. 

2.  Attempt  to  excite  respiration  by  some  form  of  irritation  applied  to  the 
skin.  Fanning  the  face  or  directing  a  current  of  air  by  means  of  a  pair  of 
bellows  is  often  of  use.  This  may  also  be  effectually  done  by  placing  the 
infant  in  warm  water  (100°  F.),  and  then  dashing  cold  water  over  it  by  means 
of  a  sponge  or  the  hand,  or  by  slapping  it  with  the  wetted  corner  of  a  towel, 
or,  if  the  faradic  current  is  at  hand,  a  feeble  current  may  be  applied  to  the 
diaphragm  and  other  inspiratory  muscles. 

3.  If  these  methods  fail,  no  time  should  be  lost  in  directly  inflating  the 
lungs  by  a  soft  catheter  passed  into  the  larynx  or  by  Richardson's  bellows, 
or  by  practising  artificial  respiration  by  Sylvester's  or  Schultz's  method, 
which  is  to  be  continued  as  long  as  the  cardiac  sounds  can  be  heard. 

Active  treatment  will  less  often  be  required  in  those  cases  of  asphyxia 
supervening  after  birth  from  non-expansion  of  the  lungs.  Gentle  measures 
may  be  undertaken  to  excite  more  active  respiratory  effects,  and  to  combat 
the  somnolence  by  means  of  hot  and  cold  water,  or  by  the  application  from 
time  to  time  of  stimulating  liniments  to  the  chest.  Such  infants,  however, 
but  feebly  respond  to  our  efforts,  and  over-treatment  in  this  direction  may 
easily  do  more  harm  than  good  ;  our  efforts  will  mainly  have  to  be  directed 
to  placing  the  infant  under  the  most  favourable  conditions  for  gaining  streng"th 
and  gradually  bringing  about  expansion  of  the  lungs  (see  p.  58). 

Apoplexia  Neonatorum. — Cerebral  haemorrhage  occurring  in  early  life 
is  hardly  ever  the  result  of  a  ruptured  artery,  but  is  almost  invariably  caused 
by  a  venous  congestion,  and  takes  place  from  the  capillary  vessels  of  the  pia 
mater  or  choroid  plexuses.  The  arteries  of  the  young  are  not  liable  to  suffer 
from^theroma,  but  retain  their  elasticity,  and,  moreover,  are  not  likely  to  have 
to  submit  to  any  unusual  strain  from  an  hypertrophied  heart.  On  the  other 
hand,  the  pia  mater  in  early  infancy  is  exceedingly  delicate  and  its  capillaries 
fragile  ;  this  can  be  readily  demonstrated  by  noticing  how  easily  it  is  stripped 
from  the  brain  by  means  of  dissecting  forceps,  and  how  loose  is  its  connection 
with  the  soft  brain  substance  beneath  it.  Further,  we  have  already  alluded 
to  the  fact  that  the  cerebral  sinuses  and  veins  become  distended  with  blood 
in  asphyxia  from  various  causes — a  rupture  of  the  capillary  vessels  of  the 
pia  mater  takes  place,  and  blood  is  effused  into  the  sub-arachnoid  space. 
This  effusion,  in  consequence  of  the  loose  connection  of  the  pia  with  the 
brain,  may  extend  over  a  large  surface,  or  burst  into  the  sub-dural  space. 
The  blood  clot  may  compress  or  lacerate  the  brain  substance,  and  if  the 
infant  lives  for  a  few  days  it  may  be  followed  by  softening.    The  hsemorrhage 


20 


The  Diseases  incident  to  Birth 


may  take  place  during  birth,  from  compression  of  the  umbilical  cord,  producing 
asphyxia,  and  is  consequently  especially  common  in  breech  presentations  ; 
or  it  may  result  from  pressure  on  the  head  by  the  uterus  or  the  blades  of  the 
forceps  (Spencer).  We  must  bear  in  mind  that  the  pia  mater  is  not  only 
very  delicate  and  its  capillaries  easily  ruptured  if  they  are  over-distended, 
but  also  that  a  stasis  is  very  apt  to  occur  in  the  superficial  veins  on  account 
of  their  peculiar  connections.  Gowers  has  laid  stress  on  the  fact  that  here 
ascending  arteries  pass  into  ascending  veins,  and,  moreover,  these  surface 
veins  empty  themselves  into  the  superior  longitudinal  sinus  in  a  forward 
direction  and  consequently  against  the  blood  current.  Thus  the  Sylvian 
vein  commences  in  the  fissure  of  that  name  and  courses  upwards  to  empty 
itself  into  the  superior  longitudinal  sinus,  receiving  the  small  veins  from  the 


'""Mf^sfJf 


Fig    5. — Meningeal  Haemorrhage  in  an  Infant  ;  death  on  the  twent^'-second  day. 
{After  McNutt.) 


motor  area  efi  route.  Near  its  commencement  the  Sylvian  vein  has^  con- 
nections with  the  superior  petrosal  sinus  (Trolard)  and  also  with  the  basilar 
vein. 

Spencer  '  comes  to  the  conclusion,  as  the  result  of  an  examination  of  the 
bodies  of  130  infants  born  dead  or  dying  soon  after  birth,  that  pressure  on 
the  skull  by  the  forceps  or  the  uterine  walls  plays  an  important  part  in  pro- 
ducing meningeal  haemorrhage.  He  believes  that  when  the  bones  of  the 
skull  are  abnormally  soft  and  the  sutures  lax,  the  lower  edge  of  the  parietal 
bone  may  press  on  the  Sylvian  vein  or  its  connections,  when  the  head  is 
subjected  to  severe  pressure  during  labour,  and  thus  a  haemorrhage  in  the 
Rolandic  area  may  be  produced  (fig.  5).     He  also  thinks  that  clamping  of  the 

1   Obstetrical  Transactiotis,  vol.  .xx.xiii. 


Apoplexia  Neonatorum  21 

internal  jugular  by  the  forceps  or  pressure  on  the  infant's  neck  by  the 
parturient  canal  may  give  rise  to  congestion  and  meningeal  haemorrhage. 
It  would  appear  from  the  observations  of  Spencer,  that,  while  these  cerebral 
haemorrhages  are  most  common  in  severe  and  instrumental  labours,  they 
are  not  unknown  in  labours  that  are  short  and  easy.  The  infant  may  live 
some  days  after  the  haemorrhage  has  taken  place,  as  in  a  case  recorded 
by  McNutt  ;  the  labour,  which  was  a  breech  presentation,  was  easy;  the 
breathing-  became  irregular  on  the  day  of  birth  ;  later  it  suffered  from  con- 
vulsions, difficulty  of  swallowing,  left  hemiplegia,  and  emaciation.  It  died  on 
the  twenty-second  day.  At  iheposf-inortcin  the  right  hemisphere  was  covered 
by  a  clot  (see  fig.  5),  which  was  firm  and  gelatinous,  and  of  a  dark  colour, 
the  convolutions  beneath  it  were  in  part  destroyed,  especially  so  in  the  ascend- 
ing frontal  and  parietal  regions.  The  clot  also  invaded  the  brain  substance, 
actually  forming  part  of  the  roof  of  the  ventricle,  whilst  the  site  of  the  corpus 
striatum  and  optic  thalamus  was  occupied  by  a  reddish-brown  clot  mixed  with 
softened  brain  tissue.  This  case  is  remarkable  as  showing  how  long  an 
infant  may  survive  an  extensive  cerebral  heemorrhage  and  the  further  damage 
by  the  secondary  inflammatory  softening  which  evidently  took  place. 

These  are  instances  of  fatal  cases,  but  there  is  good  reason  to  believe 
that  such  cases  frequently  survive,  and  bear  for  the  rest  of  their  lives  traces 
of  the  damage  done  to  their  brains  at  birth.  It  is  not  difficult  to  imagine 
the  damage  which  a  surface  heemorrhage  may  do.  It  may  lead  to  com- 
pression of  the  convolutions,  or  meningitis,  or  softening,  or  it  may  more 
likely  lead  to  atrophy,  or  interfere  with  the  development  of  the  convolutions. 
Such  a  case,  verified  by  post-mortem,  has  been  recorded  by  McNutt.  The 
infant  was  born  with  the  feet  presenting,  the  labour  was  tedious,  and  there 
was  delay  in  disengagement  of  the  head.  Convulsions  supervened,  lasting 
for  some  days  ;  the  child  never  walked  or  spoke  ;  there  was  spastic  paralysis 
of  both  sides,  except  the  face  ;  it  died  at  two  and  a  half  years.  Atrophy  of 
the  convolutions  about  the  fissure  of  Rolando  was  found  at  \kv&  post-mortetn. 
Similar  cases  are  tolerably  common  ;  there  is  a  history  of  a  difficult  labour  ; 
the  infant  is  blue,  and  perhaps  is  thought  by  the  midwife  to  be  dead  ;  it  may 
be  convulsed,  but  recovers.  There  is  probably  no  marked  paralysis  at  first, 
but  after  a  few  months  it  is  noticed  that  an  arm  or  a  leg,  or  both  legs,  are 
weak  ;  then  contractions  take  place,  the  legs  becoming  adducted,  with  the 
toes  pointing,  the  forearms  supinated,  and  the  elbows  more  or  less  fixed 
(see  Birth  Paralysis).  The  intelligence  is  often  affected,  and  the  child  is 
late  in  talking. 

HseinorrIiag:es  into  other  Viscera. — Spencer  found  in  hxs  post-nwrtet/i 
examination  of  stillborn  children  haemorrhages  into  the  lungs,  liver,  kidneys, 
intestines,  testis,  &c.  In  the  lungs  the  most  frequent  site  was  the  base,  the 
appearance  being  that  of  ordinary  pulmonary  apoplexy,  the  hsemorrhagic 
portions  being  solid  and  of  a  black  red  colour  on  section.  If  the  infant 
lives  pneumonia  may  arise.  Hsemorrhage  taking  place  into  the  kidney  may 
cause  death  during  the  first  few  days  of  life  by  suppression  of  the  urine 
(Spencer).     Hccmorrhage  into  the  bowels  may  cause  obstruction. 

Cephalhsematoma. — During  birth  a  haemorrhage  may  take  place  from 
the  vessels  of  the  periosteum  of  the  skull,  and  a  collection  of  blood  form 
between  that  membrane  and  the  bone  ;  more  rarely  a  hsemorrhage  occurs 


22 


The  Diseases  ificident  to  Birth 


between  the  occipito-frontalis  aponeurosis  and  the  periosteum,  or  between 
the  skull  and  the  dura  mater.  The  name  '  cephalhcematoma  externum '  is 
applied  to  the  first  two,  thus  : 


Cephalhaematoma  externum . 

„  internum  . 

Meningeal  heemorrhage  .     . 


Sub -aponeurotic. 
Sub-periosteal. 
Sub-cranial. 
Sub-arachnoid. 


In  the  common  form  the  tumour  is  sub-periosteal.  The  swelling, 
occupying  a  position  immediately  over  a  parietal  bone,  generally  the  right, 
is  usually  discovered  for  the  first  time  a  day  or  two  after  birth,  when  the 
swollen  and  distorted  head  of  the  infant  should  begin  to  assume  a  more 
natural  shape.  According  to  the  statistics  of  Hennig  and  Hofmokl,  a  cephal- 
haematoma  occurs  about  once  in  every  two  hundred  births  ;  in  one  hundred 
and  twenty-seven  cases  noted  by  Hennig,  it  was  situated  fifty-seven  times 

over  the  right  parietal  bone,  thirty- 
seven  times  over  the  left,  twenty- 
one  times  over  both,  seven  times 
over  the  occipital,  three  times  over 
the  frontal,  and  twice  over  the  tem- 
poral bone.  It  forms  a  more  or 
less  tense  elastic  tumour,  neither 
hot  nor  tender,  and  it  does  not 
extend  beyond  the  limits  of  the 
bone  over  which  it  is  situated,  inas- 
much as  the  periosteum  is  firmly 
attached  to  the  sutures.  The  scalp 
is  not  discoloured.  The  tumour 
varies  in  size  from  a  walnut  to  a 
small  orange,  increases  in  bulk  for 
a  few  days  after  birth,  and  then 
begins  slowly  to  diminish.  After 
it  has  existed  for  a  week  or  two, 


Fig.  6. — Double  Cephalhcematoma  in  an  Infant 
twenty  days  old  (from  a  photograph).  Labour 
difficult,  forceps  applied,  right  facial  paralysis. 


a  ridge  of  bone  may  generally  be  felt  at  its  circumference,  where  new  bone 
has  been  thrown  out  by  the  periosteum  (see  fig.  7  c').  When  the  tumour  is 
examined  for  the  first  time  in  this  stage,  it  is  apt  to  give  the  impression  that 
there  is  a  circular  defect  in  the  parietal  bone,  through  which  a  fluid  tumour 
is  protruding.  At  times,  especially  in  chronic  cases,  thin  plates  of  bone  form 
here  and  there  in  the  periosteum  forming  the  roof  of  the  tumour  and  give 
rise  to  a  feeling  of  crepitation  when  it  is  handled.  In  the  course  of  a  few 
weeks  or  a  month  the  tumour  shrinks  and  disappears,  leaving  for  perhaps 
many  months  a  more  or  less  complete  bony  ridge,  which  marked  the  circum- 
ference of  the  tumour.  The  etiology  of  these  blood-swellings  is  not  very 
clear,  but,  like  other  haemorrhages  which  take  place  during  birth,  they  owe 
their  production  in  part  to  asphyxia,  in  which  there  is  increased  tension  in 
the  cranial  veins,  and  a  condition  of  blood  which  readily  allows  of  extravasa- 
tion. From  the  fact  that  the  tumour  mostly  occurs  at  the  site  of  the  caput 
succedaneum,  being  over  the  right  parietal  bone  in  nearly  three-fourths  of 


Cephalhceviatoma 


23 


the  cases,  it  would  appear  that  pressure  upon  the  head  played  an  important 
part  in  its  causation  ;  but,  on  the  other  hand,  cases  are  reported  in  which  a 
ijlood-swelling  appeared  over  a  parietal  bone  in  a  case  of  breech  presen- 
tation (Runge,  McNutt).  Small  extravasations,  the  size  of  a  pea  or  a 
shilling,  may  freciuently  be  seen  beneath  the  periosteum  in  making  post- 
mortems oxv  n&\\\y  horn  infants.  If  the  caput  succedaneum  be  incised,  the 
tissues  immediately  beneath  the  scalp  will  be  found  infiltrated  with  a  jelly- 
like effusion  with  numerous  minute  haemorrhages  scattered  through  it,  and 
on  examining  the  parietal  bone  numerous  small  haemorrhages  may  be  seen 
beneath  the  periosteum,  some  linear  in  shape,  corresponding  with  the  lines 
or  foramina  in  the  bone  situated  near  the  inter-parietal  suture  or  posterior 
fontanelle.  According  to  Fere  the  edges  of  the  foramina  play  an  important 
part  in  wounding  the  vessels  during  labour,  and  producing  a  haemorrhage, 
as  they  are  the  means  of  transmitting  small  veins  from  the  scalp  to  the 
cerebral  sinuses.  It  is  important  to  bear  in  mind  that  not  infrequently  an 
effusion  of  blood  external  to  the  skull  communicates  with  an  effusion  of 
blood  between  the  bone  and  dura  mater  through  one  of  these  openings,  and, 
further,  a  meningeal  haemorrhage  may  also  take  place. 


Fig.  7. — Section  of  a  Cephalhaematoma  (semi-diagrammatic),  Hennig.     a,  Dura  mater  ; 
b,  parietal  bone  ;  c,  periosteum  ;  c',  ossification  of  ditto  ;  d,  scalp  ;  e,  blood  clot. 


The  diagnosis  is  not  generally  a  matter  of  difficulty.  A  blood  tumour 
beneath  the  periosteum  is  distinguished  from  a  caput  succedaneum^  inasmuch 
as  the  latter  does  not  fluctuate,  disappears  in  a  day  or  two,  and  extends 
beyond  the  limits  of  a  parietal  bone.  It  is  distinguished  from  a  meningocele  in 
that  the  latter  corresponds  to  a  suture  or  fontanelle,  pulsates,  and  increases  in 
size  when  the  infant  cries.  Very  rarely  a  blood-swelling  takes  place  beneath 
the  scalp,  between  the  latter  and  the  periosteum.  In  such  cases  the  scalp  is 
discoloured,  no  bony  ring  would  be  formed,  and  the  swelling  might  extend 
beyond  the  sutures.  The  prognosis  as  far  as  a  cephalhaematoma  is  con- 
cerned is  favourable,  but  inasmuch  as  it  is  possible  that  it  is  complicated  by 
meningeal  or  extra-dural  haemorrhage  the  prognosis  must  be  guarded,  and 
any  brain  symptoms  are  necessarily  of  evil  omen. 

Treatment. — The  treatment  of  these  blood  swellings  has  been  much 
discussed.  On  the  one  hand,  it  has  been  urged  that  if  the  cephalhematoma 
is  subperiosteal,  it  should  be  aspirated  without  delay  while  the  blood  is 
fluid  and  before  coagulation  has  taken  place,  as  in  this  way  the  long  delay 
during  which  absorption  and  deposition  of  bone  are  taking  place  is  avoided. 


24  -The  Diseases  incident  to  Birth 

On  the  other  hand,  it  has  been  pointed  out  that  it  is  never  possible  to  tell  if 
the  blood  swelling  does  not  communicate  with  a  blood  extravasation  within 
the  skull,  thus  rendering  surgical  interference  risky,  and  moreover  that 
although  absorption  of  the  effused  material  may  be  tardy,  it  is  both  safe  and 
sure,  and  a  good  result  may  be  confidently  looked  forward  to.  The  latter 
course  is  certainly  to  be  recommended  ;  surgical  interference  in  a  newly  born 
infant  always  has  its  risks,  there  is  always  the  possibility  of  introducing 
septic  organisms  into  the  blood  swelling  by  aspiration,  and  at  the  most  all 
that  is  to  be  gained  by  such  a  proceeding  is  the  saving  of  a  few  weeks  of  tiine. 
We  believe  that  all  cephalhcematomata  are  most  safely  let  alone,  care  being 
taken  to  protect  them  from  injury  ;  small  ones  may  be  shaved  and  painted 
with  collodion,  or  during  sleep  some  spirit  lotion  may  be  kept  applied.  In  the 
rare  event  of  their  suppurating  the  treatment  would  be  that  of  an  ordinary 
abscess — viz.  evacuation  of  the  pus  and  drainage. 

Kaematoma  of  the  Sterno-mastoid. — If  an  attempt  be  made  by  an  un- 
skilful midwife  to  disengage  the  after-coming  head  by  pulling  on  the  legs  or 
body  of  the  infant,  there  is  a  strong  probability  that  injury  will  be  done  to 
the  neck  or  other  part,  especially  as  the  muscles  of  the  semi-asphyxiated 
infant  are  flabby  and  toneless,  and  the  blood  readily  oozes  out  of  the  vessels. 
Such  an  injury  does  at  times  take  place,  giving  rise  to  a  blood  tumour  within 
the  sheath  of  one.of  the  sterno-mastoids  in  consequence  of  the  tearing  through 
of  some  of  the  fibres  of  the  muscle  or  injury  to  some  of  its  vessels.  The 
swelling  appears  to  be  actually  composed  at  first  of  blood  and  of  the  retracted 
torn  muscle,  later  no  doubt  of  inflammatory  material  resulting  from  the  injury, 
and  in  some  cases  where  a  permanent  thickening  remains  it  is  due  to  cica- 
trised tissue  round  the  torn  and  retracted  muscle.  Thus  we  have  seen  the  cla- 
vicular part  of  the  muscle  torn  away  from  its  attachment,  and  a  swelling  at  the 
junction  of  the  two  bellies.  It  is  not  often  that  an  opportunity  occurs  of  veri- 
fying this  condition  post  fuortem,  inasmuch  as  no  serious  consequences  arise 
from  the  accident,  but  the  investigations  of  Tordeus,  Spencer,  and  others 
make  it  clear  that  these  swellings  are  due  to  local  injuries  at  birth.  In  one 
of  our  own  cases  in  which  the  infant  died  of  diarrhoea  when  six  months  old,  a 
cicatrisation  of  the  muscle  at  the  spot  where  the  injury  had  taken  place  was 
found.  In  another  case  we  had  also  the  opportunity  of  2l  post-mortem.  At 
least  three-fourths  of  these  cases  are  breech  presentations  :  in  the  remaining 
fourth,  which  occur  in  head  presentations,  the  injury  is  no  doubt  caused  by 
dragging  on  the  head  in  order  to  disengage  the  shoulders  and  body.  The 
swelling  in  the  neck  may  be  noticed  by  the  mother  a  few  days  after  birth,  or 
it  may  escape  observation  for  some  weeks,  or  even  more.  On  examination 
a  tumour  about  the  size  of  a  pigeon's  ^%^  may  be  felt  in  the  upper  part  of  the 
right  sterno-mastoid  ;  it  is  generally  irregular,  or  perhaps  elongated,  in  shape, 
and  if  not  seen  for  sometime  after  birth,  when  cicatrisation  has  taken  place, 
it  is  hard  and  cartilaginous  to  the  touch.  The  left  muscle  is  less  often  injured 
than  the  right  ;  sometimes  the  whole  length  of  the  muscle  is  affected,  though 
the  lesion  is  generally  in  the  upper  part.  The  tumour  disappears  in  the 
course  of  a  few  months,  but  for  a  long  time  a  cicatrix  may  be  felt.  There  is 
no  treatment  required.  These  cases  mostly  occur  among  the  poorer  classes, 
who  are  attended  in  their  confinements  by  neighbours  or  unskilled  midwives. 
Injury  to  the  sterno-mastoid  during  birth  derives  its  importance  from  the 


Occipital  Hcematoma  25 

fact  that  such  injury  is  likely  to  be  the  cause  of  wry  neck  in  after  life  (see 
Torticollis).' 

Occipital  Hsematoma. —  Injury  to  other  muscles  may  occur  during  birth, 
and  we  have  seen  in  one  case  a  '  tumour'  in  connection  with  the  muscles  at 
the  back  of  the  neck  arising  from  injury  during  birth.  It  was  a  head  presen- 
tation, and  there  was  also  asterno-mastoid  '  tumour.'  The  child  was  seen  at 
five  weeks  old.  Labour  had  been  prolonged,  head  delivered  by  forceps  with 
much  difficulty,  and  subsecjuently  severe  traction  was  needed  to  extract  the 
body.  Two  symmetrical  swellings  were  felt  in  the  muscles  at  the  back  of  the 
neck,  evidently  due  to  haematoma.  There  was  left  facial  paralysis  and  para- 
lysis of  the  left  arm.  The  child  was  heard  of  two  years  later,  and  it  was  said 
to  have  completely  recovered. 

Obstetrical  Paralyses. —  In  cases  of  delayed  labour,  where  the  forceps 
have  to  be  applied,  or  where  force  is  used  to  disengage  an  arm  or  traction 
is  applied  to  it,  some  nerves  or  strands  of  nerves  are  apt  to  be  injured  either  by 
stretching,  direct  pressure,  or  compression  by  extravasated  blood.  The  most 
common  and  best  known  is  an  injury  to  one  of  the  facial  nerves  through  pres- 
sure exerted  by  one  of  the  blades  of  the  forceps  during  extraction.  A  facial 
paralysis  is  thus  produced,  which  as  a  rule  is  temporary,  and  disappears  in  a 
few  days  or  weeks.  The  other  and  less  common  form,  which  has  been  de- 
scribed by  Duchenne  as  '  obstetrical  paralysis,'  is  due  to  an  injury  of  one  or 
other  of  the  cords  of  the  brachial  plexus,  produced  by  the  pressure  of  the  finger 
hooked  in  the  axilla  in  order  to  extract  the  arm  and  shoulders,  or  the  arm  has 
been  forcibly  wrenched  when  it  has  been  used  to  lay  hold  of  to  drag  the  infant 
through  the  pelvis.  Occasionally  an  injury  may  be  done  to  the  brachial  plexus 
as  well  as  to  the  facial  by  the  grip  of  the  forceps  blades,  as  in  a  case  recorded 
by  Roger,  where  the  face  and  arm  were  paralysed.  After  death  an  effusion 
of  blood  was  found  at  the  stylo-mastoid  foramen,  and  also  round  the  cords  of 
the  brachial  plexus.  The  cord  most  often  injured  is  apparently  the  fifth  cer- 
vical nerve,  which,  as  Ross  has  shown,  is  readily  injured,  at  the  point  where 
it  descends  over  the  transverse  processes  of  the  fifth  and  sixth  cervical  ver- 
tebras on  its  way  to  join  the  brachial  plexus,  by  force  applied  to  the  arm  or 
clavicle.  The  prognosis  in  paralysis  of  the  arm  from  a  lesion  of  the  brachial 
plexus  is  more  serious  than  it  is  in  paralysis  of  the  face,  but  it  will  neces- 
sarily vary  according  to  the  amount  of  injury  done  and  the  degree  of  para- 
lysis present.  The  symptoms  presented  by  this  form  of  paralysis  may  be 
illustrated  by  the  following  cases  which  came  under  our  notice. 

In  the  first  case,  the  head,  according  to  the  mother,  was  born  first  ;  there 
was  then  a  delay  ;  finally  the  left  arm  was  disengaged  by  the  finger  hooked  in 
the  axilla,  and  the  child  born  after  some  delay  and  difficulty.  The  infant  was 
first  seen  when  seven  weeks  old.  At  this  time  its  arm  hung  uselessly  by  its 
side,  the  elbow  extended,  the  humerus  rotated  inwards  and  adducted,  the 
forearm  pronated,  the  hand  closed  (in  some  cases  the  hand  is  open,  the  palm 
turned  backwards  on  account  of  the  supination  of  the  forearm),  the  paralysed 
muscles  being  the  biceps  and  brachialis  anticus,  the  infraspinatus  and  teres 
minor,  the  deltoid  and  supinators.  The  muscles  affected  were  soft  and  flabby. 
The  arm  was  regularly  galvanised,  the  faradic  current  being  used.     Three 

'  See  also  D'Arcy  Power,  Med.. Chi r.  Trans,  vol.  Ixxvi.  who  gives  a  list  of  cases  from 
Glutton  and  others'  observations  as  well  as  his  own. 


26  The  Diseases  incident  to  Birth 

years  afterwards  great  improvement  had  taken  place  ;  the  elbow  could  be 
flexed  and  the  hand  could  be  used,  but  a  paresis  remained  of  the  deltoid  and 
supinators.  In  another  case,  seen  first  at  ten  weeks  of  age,  the  same  muscles 
were  paralysed,  much  improvement  took  place,  but  the  infant  died  at  six 
months  old  of  bronchitis.  In  a  third  case,  which  was  a  footling,  the  left  arm 
engaged  the  pelvis  with  the  head,  and  had  to  be  brought  down  by  the 
accoucheur.  The  arm  was  noticed  to  be  bruised  and  useless  after  birth.  Un- 
fortunately this  case  was  lost  sight  of.  In  another  case  seen  by  us,  both  arms 
were  almost  completely  paralysed,  only  the  fingers  in  one  hand  retaining  some 
power  of  flexion.  The  mother  had  a  contracted  pelvis,  the  head  presented, 
the  medical  man  turned  and  delivered  with  much  difficulty  ;  there  was  also  a 
sterno-mastoid  hsematoma.  In  two  cases  reported — one  by  Seeligmiiller,  the 
other  by  Thorburn — the  paralysis  was  more  extensive  than  in  the  above  cases  ; 
there  was  also  retraction  of  the  eyeball  and  contraction  of  the  pupil  of  the 
same  side.  Probably  there  was  here  a  more  severe  injury,  involving  the 
whole  brachial  plexus  and  also  the  sympathetic.  In  some  cases  a  temporary 
ansesthesia  has  been  noticed.  In  the  treatment  of  these  cases  it  must  be 
borne  in  mind  that  one  or  more  of  the  cords  of  the  brachial  plexus  has  been 
injured,  accompanied  by  a  local  htemorrhage  ;  and  therefore,  the  more  at  rest 
the  arm  can  be  kept  for  the  first  few  weeks  the  better.  It  seems  doubtful  if 
any  shampooing  or  galvanising  of  the  muscles  can  at  first  do  much  good. 
The  treatment  must  be  rather  that  of  a  fractured  bone — rest  at  first,  and 
afterwards  more  or  less  active  movement  to  exercise  the  muscles  and  prevent 
stiflhess.  The  arm  should  be  carefully  wrapped  up  in  cotton  wool,  flexed  and 
supported  by  being  fixed  to  the  side,  care  being  taken  to  prevent  undue 
disturbance  during  the  daily  bath,  or  allowing  it  to  hang  down  and  drag  on  its 
connections  with  the  trunk.  It  must  be  borne  in  mind  that  the  circulation 
of  blood  will  be  sluggish,  and  easily  obstructed  by  tight  bandaging.  At  the 
end  of  three  weeks,  when  there  is  reason  to  believe  that  absorption  of  the 
effused  blood  has  taken  place,  movements  of  the  arm  may  be  begun,  in  order 
to  give  the  muscles  some  exercise  and  to  call  forth  the  voluntary  efforts  of 
the  child.  Galvanism,  shampooing  the  muscles,  applying  stimulant  applica- 
tions to  the  skin,  must  be  persevered  with  as  long  as  any  improvement  takes 
place.  The  prognosis  in  the  severe  cases  is  gloomy  as  far  as  the  paralysed 
muscles  are  concerned  ;  the  arm  remains  in  a  condition  of  extension  and 
pronation,  and  is  unable  to  be  raised  to  the  mouth.  In  other  cases,  as  in 
the  one  mentioned,  recovery  takes  place  sufficiently  to  allow  of  flexion  of  the 
elbow,  though  a  certain  amount  of  weakness  may  be  left  about  the  shoulder 
and  in  the  supinators  of  the  wrist.  The  biceps  usually  is  the  first  to  recover, 
while  the  deltoid  and  supinators  are  the  last,  if  indeed  they  recover  at  all. 

Icterus  TTeonatorum. — Infants  often  suffer  from  a  more  or  less  pro- 
nounced jaundice  which  comes  on  a  day  or  two  after  birth.  It  has  been 
estimated  by  Continental  writers  that  this  occurs  in  from  60  to  80  per 
cent,  of  the  total  births  ;  but  these  observations  have  been  mostly  made  in 
lying-in  hospitals,  where  it  appears  to  occur  much  oftener  than  in  private 
practice,  though  there  is  little  doubt  that  on  account  of  the  slightness  of  the 
yellow  coloration  of  the  skin,  and  the  frequent  absence  of  discoloration  of 
the  sclerotic,  it  may  easily  be  overlooked.  Jaundice  may  arise  from  or  be 
symptomatic  of  various  pathological  conditions,  the  principal  durmg  the  first 


Icterus  Neonatorum  27 

week  of  life  being  the  following  :  i.  The.  common  form  in  which  no  disease 
is  apparent — icterus  neonatorum.  2.  Jaundice  accompanying  a  condition 
of  septicaemia  or  pyaemia  ;  in  acute  fatty  degeneration  of  the  newly  born  ; 
in  Winckel's  disease.  3.  Jaundice  due  to  congenital  stricture,  or  oblitera- 
tion of  the  common  or  hepatic  duct,  or  to  syphilitic  perihepatitis.  The 
common  form  to  which  the  name  of  '  icterus  neonatorum '  is  generally 
applied  differs  from  the  other  forms  in  not  being  accompanied  by  any  serious 
symptoms,  and  in  passing  off  in  a  few  days  or  a  week.  In  these  cases  the 
yellow  coloration  of  the  skin  makes  its  appearance  on  the  second  day,  less 
often  the  third,  rarely  either  before  the  second  or  after  the  third,  and  lasts, 
according  to  its  intensity,  from  two  or  three  days  to  a  week.  The  yellowness 
is  first  noted  on  the  face,  around  the  mouth  and  chest,  then  on  the  abdomen, 
later  on  the  limbs  ;  it  may  be  easily  overlooked,  unless  pressure  is  made  by 
the  finger  on  the  skin.  In  mild  cases  the  sclerotics  remain  unaffected,  and 
the  urine  does  not  stain  the  linen  ;  this  is  the  more  noteworthy,  as  in  the 
jaundice  of  adults  the  sclerotics  are  affected  before  the  skin  is  tinged,  and 
pigment  is  very  early  present  in  the  urine  ;  probably  the  vascularity  and 
transparency  of  the  infant's  skin  account  for  the  difference.  When  the 
jaundice  in  the  infant  is  more  intense,  the  sclerotics  become  tinged  ;  the 
urine  stains  the  diapers,  and  bile  pigment  may  be  detected.  The  stools  are 
unchanged  and  contain  the  usual  quantity  of  bile.  In  cases  which  die  when 
suffering  from  this  form  of  jaundice,  the  internal  organs  are  found  stained 
yellow,  especially  the  cartilages,  the  brain,  and  in  a  lesser  degree  the  abdo- 
minal viscera.  The  majority  of  infants  who  are  jaundiced  appear  in  perfect 
health  ;  it  has,  however,  been  asserted  by  Hofmeier  that  infants  with  icterus 
do  not  flourish  as  well  as  other  infants,  that  their  loss  of  weight  during  the 
first  week  is  greater  than  that  of  healthy  infants,  and  that  a  higher  per- 
centage of  urea  and  uric  acid  appears  in  the  urine.  The  cause  of  this  form 
of  jaundice  is  uncertain  ;  it  is  much  more  frequent  in  lying-in  hospitals 
than  in  private  practice,  and  in  premature  weakly  infants  with  partially 
expanded  lungs  than  in  full-time  and  healthy  infants.  There  have  been 
many  hypotheses  concerning  its  cause,  but  none  of  them  are  entirely  satis- 
factory. One  of  the  most  plausible  explanations  has  been  suggested  by 
Quincke  ;  he  attributes  the  jaundice  to  the  ductus  venosus  remaining  patent, 
thus  allowing  some  of  the  portal  blood  (which  contains  bile  pigments)  to  pass 
into  the  general  circulation,  instead  of  all  of  it  being  submitted  to  the  action 
of  the  liver.  Virchow  and  others  believe  it  to  be  a  hsematogenous  jaundice, 
the  bile  pigment  originating  in  a  destruction  of  blood  corpuscles  which  it  is 
supposed  takes  place  shortly  after  birth. 

While  this  form  of  jaundice  \s  per  se  a  symptom  of  little  importance,  and 
in  the  vast  majority  of  cases  the  infants  do  well,  it  is  well  to  remember  that 
occasionally  cases  occur  which  are  jaundiced  shortly  after  birth,  and  which 
die  about  the  ninth  or  tenth  day  without  any  definite  disease  being  discover- 
able. These  cases  sometimes  occur  in  the  same  family,  as  in  the  following 
remarkable  instances  :  the  father  and  mother  were  both  healthy  and  in 
comfortable  circumstances,  there  was  no  history  of  syphilis,  the  first  and 
second  children  were  never  jaundiced,  and  are  at  present  alive  and  well  ;  the 
third,  fourth,  fifth,  and  sixth  children  became  jaundiced  on  the  second  or 
thirS  day,  and  died  on  the  ninth  or  eleventh  day.     In  all,  the  skin  and  con- 


28  The  Diseases  incident  to  Birth 

junctivtE  were  jaundiced,  the  urine  contained  bile  pigment,  the  stools  were 
normal.  The  fifth  child  was  seen  with  Mr.  G.  H.  Pinder,  their  medical 
attendant,  when  five  days  old  ;  it  seemed  a  perfectly  healthy  infant,  except 
that  it  was  jaundiced.  The  infant  became  weaker  and  drowsy,  and  died 
comatose  on  the  ninth  day.  A  partial  post-vtorteni  only  was  obtained  ;  the 
abdominal  viscera  were  bile-stained  ;  the  ductus  venosus  was  only  partially 
closed  ;  there  was  nothing  abnormal  about  the  bile-ducts.  What  is  the 
nature  of  these  and  similar  cases  it  is  at  present  impossible  to  say.  We  have 
seen  several  other  similar  cases,  where  infants  have  become  jaundiced 
shortly  after  birth  and  died  in  a  few  days  without  any  apparent  explanation. 
The  diagnosis  between  icterus  neonatorum  and  the  jaundice  which  accom- 
panies septicaemia  does  not  present  much  difficulty,  for  in  the  latter  case 
there  would  be  some  suppuration  or  phlebitis  of  the  umbilical  cord  or  ecchy- 
mosis  and  various  heemorrhages.  In  acute  fatty  degeneration  and  Winckel's 
disease  there  are  usually  cyanosis,  purpuric  spots,  and  hfemorrhages.  In 
jaundice  from  obstruction  of  the  ducts,  the  jaundice  is  intense  and  bile  is 
absent  from  the  stools.  Nothing  much  can  be  said  about  the  treatment  of 
infantile  jaundice,  which  consists  rather  in  attending  carefully  to  the  general 
health  of  the  infant  than  in  the  administration  of  any  special  drug.  Small 
doses  of  hyd.  c.  cret.  may  be  given  for  its  laxative  effect,  and  to  relieve  any 
tendency  to  mechanical  congestion  of  the  liver. 

Hsemorrhagric  Diathesis.  Hsemopbilia  Neonatorum. —  It  not  infre- 
cjuently  happens  that  within  a  few  days  of  birth  the  infant  exhibits  a  tendency 
to  bleed.  There  may  be  hemorrhages  from  the  nose,  stomach,  bowels, 
or  kidneys,  and  petechite  and  ecchymoses  may  make  their  appearance  on  the 
skin.  Oozing  of  blood,  which  is  perhaps  difficult  to  arrest,  may  take  place 
from  the  navel  on  the  separation  of  the  cord.  This  tendency  to  bleed  is  no 
doubt  to  be  looked  upon  as  rather  a  symptom  than  a  disease  or  the  result  of 
disease.  It  cannot  be  said  that  our  knowledge  is  very  exact  regarding  the 
conditions  which  give  rise  to  the  htemorrhagic  diathesis  in  infants,  but  in  a 
large  majority  of  cases  at  least  the  infant  is  either  syphilitic  or  suffers  from 
septicaemia  or  from  both  conditions.  The  poisons  generated  by  the  syphilitic 
or  septic  infection  appear  to  cause  such  changes  in  the  blood  as  give  rise 
to  bleeding  on  the  slightest  injury.  In  some  of  the  cases  in  which  there  was 
no  evidence  of  syphilis  during  life,  the  evidence  has  been  forthcoming  at  the 
post-mortem^  and,  moreover,  S)'philis  is  not  disproved  by  no  lesions  being 
discovered  in  an  infant  a  few  days  old. 

In  seven  cases  recorded  by  FischP  in  which  haemorrhages  took  place 
shortly  after  birth  from  the  mucous  membranes  or  into  the  skin,  there  was 
evidence  of  syphilis  ;  there  being  characteristic  rashes  on  the  skin,  enlarge- 
ment of  the  spleen,  and  interstitial  hepatitis.  In  one  of  the  author's 
cases,  however,  the  only  evidence  of  syphilis  was  the  enlargement  of  the 
spleen  and  an  interstitial  hepatitis.  A  careful  microscopical  examination  of 
the  minute  blood-vessels  was  made  in  these  cases,  with  the  result  that  they 
\vere  found  normal,  so  that  the  bleeding  could  not  be  attributed  to  arteritis. 

In  three  cases  of  haemophilia  in  infants  recently  investigated  by  H. 
Neumann-  pyogenic  organisms  were  found,  and  the  author  inclines  to  the 

1  Archill  fur  Kinderheilk.     Band  viii. 
^  Ibid.  Bande  xii.  xiii. 


Hieinorrhagic  Diathesis — Hczmophilia  Neonatorum         29 

Ijelief  that  the  entrance  of  the  septic  organisms  into  the  system  either  laefore 
or  during  the  act  of  birth  had  much  to  do  with  the  hccmorrhagic  state.  In 
the  tirst  case  the  infant,  which  was  illegitimate,  suftered  from  jaundice,  petechia; 
on  the  skin,  mehena,  and  hiematemesis  ;  it  died  on  the  fifteenth  day.  The 
autopsy  showed  there  had  been  capillary  bleeding  from  the  mucous  mem- 
brane of  the  alimentary  canal,  enlargement  of  the  spleen,  and  interstitial 
hepatitis  (syphilitic).  A  bacteriological  examination  of  the  blood  showed  the 
presence  of  the  Bacillus  pyocyaneus  13.  In  a  second  case,  undoubtedly 
syphilitic  (snuffles  and  rash),  which  suffered  from  bleeding  from  the  nose  and 
mouth,  and  which  died  when  seven  weeks  old,  a  bacteriological  examination 
showed  the  presence  of  pus  cocci,  namely,  Staphylococcus  pyogenes  aureus 
and  albus  and  also  Streptococcus  pyogenes.  In  a  third  case,  in  which  the 
mother  suffered  from  syphilitic  ulceration  of  the  labia,  the  infant  suffered 
from  jaundice  and  various  haemorrhages,  and  died  on  the  ninth  day.  Both 
bacilli  and  cocci  {Bacillus  pyocyan.  13  and  Staphyloc.  pyog.  aureus)  were 
found  in  the  blood.  It  is  not  easy  to  say  in  the  present  state  of  our  know- 
ledge whether  the  bacilli  and  cocci  found  were  accidentally  present,  or 
whether  the}'  were  directly  or  indirectly  the  cause  of  the  blood  change  which 
gave  rise  to  the  blood  extravasations.  The  bacilli  may  enter  the  foetal  tissues 
before  bii'th  through  the  placental  circulation  or  be  inoculated  at  the  time  of 
birth  or  afterwards  through  the  navel. 

Acute  Patty  Degreneration  of  the  Newly  Born, — Buhl,  in  1861,  de- 
scribed the  symptoms  and  morbid  anatomy  of  a  rare  disease,  occurring  in 
newly  born  infants,  to  which  he  gave  the  tiame  of  acute  fatty  degeneration. 
His  observations  have  since  been  confirmed  by  Hecker,  Furstenburg,  Roloff, 
and  Runge,  though  it  cannot  be  said  that  this  condition  is  sufficiently  well 
known  for  it  to  take  its  place  as  a  well-defined  and  definite  disease.  The 
infants  suffering  from  it  are  generally  born  in  a  condition  of  asphyxia  with- 
out obvious  cause,  and  some  die  asphyxiated.  If  they  survive,  they  usually 
suffer  from  more  or  less  cyanosis,  with  haemorrhage  from  the  bowels, 
stomach,  or  from  the  navel  on  the  separation  of  the  cord.  There  is  often 
jaundice,  and  blood  extravasations  take  place  beneath  the  skin,  conjunctiva, 
or  mucous  membrane  of  the  mouth  ;  there  may  be  general  oedema  ;  death 
usually  takes  place  within  two  weeks.  At  the  post-jnortem  minute  hsemor- 
rhages  are  found  in  the  various  internal  organs,  which  are  sometimes  infil- 
trated with  blood  ;  the  tissues  are  bile-stained.  On  microscopical  examina- 
tion of  the  tissues  of  the  heart,  liver,  kidneys,  &c.,  they  are  found  to  be  in  a 
condition  of  fatty  degeneration.  The  nature  of  the  disease  is  quite  unknown. 
It  is  interesting  to  note  that  a  similar  condition  has  been  observed  in  newly 
born  pigs  and  other  domesticated  animals. 

Winckel's  Disease. — .\  disease  somewhat  similar  to  the  last  has  been 
described  as  occurring  in  an  epidemic  form  by  Winckel,  and  is  characterised 
by  cyanosis,  jaundice,  and  ha^moglobinuria.  This  epidemic  occurred  in  the 
Foundling  Hospital  at  Dresden  in  1879,  where  twenty-three  infants  were 
affected  in  the  course  of  a  month.  The  symptoms  noted  were  first  of  all  a 
bluish  tinge  on  the  skin  of  the  face,  body,  and  limbs,  with  a  more  or  less 
icteric  tint  ;  in  some  cases  there  were  vomiting  and  diarrhcea.  The  urine 
was  of  a  light  brown  colour,  with  a  sediment  consisting  of  epithelium  and 
casts  ;  the  blood  contained  an  excess  of  white  corpuscles  and  many  granular 


30  The  Diseases  incident  to  Birth 

bodies.  The  symptoms  usually  began  on  the  fourth  day  after  birth,  death 
occurring  in  one  case  in  nine  hours,  though  the  average  duration  of  the 
disease  was  about  two  days.  The  sections  showed  a  yellow  staining  of  the 
skin  and  internal  organs.  The  spleen  was  large  and  hard  and  dark  red  ; 
the  kidneys  were  usually  dark  brown  in  colour,  the  microscopic  examination 
showing  their  tubules  to  be  filled  with  granular  pigment.  There  were  puncti- 
form  haemorrhages  on  the  surface  of  the  various  internal  organs,  and  fatty 
degeneration  of  the  liver  and  heart. 

Gastro-intestinal  Kaemorrhag'e. — -The  vomiting  of  blood,  or  its  passage 
per  anum,  is  not  an  uncommon  occurrence  in  the  newly  born.  The  most 
common  cause,  especially  of  ha^matemesis,  is  the  swallowing  of  blood  oozing 
from  a  cracked  nipple,  which  the  infant  sucks,  or  from  some  wound  in  the 
infant's  mouth  or  nose.  Large  quantities  of  blood  may  be  swallowed  in  this 
way,  and  vomited  in  a  more  or  less  altered  condition,  or  passed  as  blackish 
masses  with  the  faeces.  A  hemorrhage  may  have  taken  place  into  the 
bowel  during  labour  and  the  blood  passed  in  the  stools.  A  much  more 
serious  condition  exists  when  the  source  of  the  bleeding  is  a  small  ulcer  or 
ulcers  in  the  stomach  or  duodenum,  which  may  open  a  large  vessel  and 
cause  fatal  haemorrhage,  as  in  a  case  recorded  by  Goodhart  and  another  by 
Sawtell.  Neumann  has  recorded  a  somewhat  similar  case  in  an  infant 
born  of  healthy  parents,  which  died  on  the  third  day  from  birth  after 
vomiting  blood.  At  the  post-mortem  an  ulcer  was  found  in  the  duodenum. 
In  the  majority  of  cases  the  bleeding  appears  to  be  capillary,  due  to  a 
tendency  to  haemophilia,  which  has  been  described  (p.  28).  The  haemorrhage 
in  most  instances  comes  on  within  the  first  twenty-four  hours  ;  if  the 
amount  of  blood  lost  is  large,  the  infant  quickly  becomes  pallid,  the  skin 
cold,  the  fontanelles  depressed,  and  convulsions  probably  follow.  Death 
usually  takes  place  within  twenty-four  hours  of  the  commencement  of  the 
symptoms  ;  if  the  infant  survives  this  period  and  no  fresh  attack  comes  on, 
there  is  reason  to  believe  there  is  no  lesion  of  the  stomach  or  duodenum, 
and  there  is  good  hope  that  the  infant  may  survive.  The  treatment  would 
naturally  depend  upon  the  diagnosis  as  to  the  cause.  Small  doses  of 
ergotine  (quarter  grain  to  half  grain),  in  syrup,  by  the  mouth  or  sub- 
cutaneously,  would  be  the  most  likely  to  be  of  service.  In  any  case  of 
passage  of  blood  per  rectum  in  an  infant,  the  possibility  of  an  invagination 
of  the  intestine  must  be  borne  in  mind. 

Hsemorrliag'e  from  the  Genital  Org-ans. — It  sometimes  happens  that 
there  is  a  small  oozing  of  blood  from  the  vagina  during  the  first  few  days 
succeeding  birth,  sufficient  to  stain  the  napkms.  The  blood  may  often  be 
seen  oozing  from  the  vagina,  while  no  lesion  of  any  kind  can  be  detected. 
The  discharge  lasts  for  a  few  days  only,  generally  from  two  to  five,  the  health 
of  the  infant  does  not  suffer,  and  recovery  seems  always  to  take  place. 
Cullingworth  has  collected  thirty-two  such  cases,  two  of  which  came  under 
his  own  observation.  He  agrees  with  Cameron  in  believing  that  the  bleed- 
ing is  due  to  a  congestion  of  the  pelvic  veins,  the  result  of  the  cessation  of  the 
circulation  in  the  umbilical  arteries  when  the  cord  is  tied.  As  already  stated, 
there  is  sometimes  a  coincident  discharge  of  blood  from  the  rectum,  due 
apparently  to  the  same  cause  (see  also  p.  21).     It  must  not  be  forgotten  that 


Diseases  of  tJie  Navel —  Umbilical  Polypus  3  1 

cases    of  precocious    menstruation    may   occur,    commencing  shortly   after 
birth,  and  continuing  monthly  afterwards. 

Diseases  of  the  Navel.  Separation  of  the  Cord. — Under  ordinary 
circumstances  the  umbilical  cord  shrivels  up  and  drops  off  at  a  period  after 
birth  varying  from  the  first  to  the  fifth  day,  thin  small  cords  drying  up  and 
separating  earlier  than  large  soft  ones  (Bouchut)  ;  the  cicatrix  is  not  usually 
dry  and  firm  until  the  tenth  or  twelfth  day. 

Umbilical  Polypus. — Occasionally,  after  the  cord  has  separated,  a  small 
red  prominent  projection  is  left  with  a  moist  surface,  and  sometimes  (Holmes) 
a  fine  central  canal  ;  this  '  polypus  '  is  the  result  in  most  cases  of  incomplete 
withering  of  the  cord,  at  other  times  the  outgrowth  is  rather  of  the  nature  ot 
a  simple  granulation    polypus  from  irritation,  the   so-called   'fungus  of  the 
navel.'     The   projection,   when   small,   is   often   hidden  by  the   overhanging 
skin  of  the  part,  and  may  remain  for  weeks  or  months,  giving  rise  to  slight 
discharge  from  the  scar  and   perhaps   excoriation   of  the   skin  around.     In 
another  class  of  cases,  such  as  one  sent  to  us  by  Dr.   Serra,  of  Eccles,  the 
proximal  part  of  the  cord  instead  of 
shrivelling  up  remained  as  a  red  vascu- 
lar projection  some  three  inches  long. 
On  examining  this  child  some  five  or 
six  weeks  after  birth,  there  was  a  red 
fleshy  prominence  then  about  ih  inch 
long  projecting  from  the  navel  ;  it  was 
about  as  thick  as  a  cedar  pencil,  and 
its   surface  appeared  to  be  a  mucous 
membrane  except  at  one  spot  where  a 
patch  of  delicate  cuticle  was  found.  The 
apex  of  the  protrusion  was  perforated 
by  an  orifice  which   readily  admitted 
an  ordinary  probe,  and  the  instrument 
could   be   passed    downwards   in    the 
middle  line  and  swept  round  on  each 
side  for  some  three  inches  ;  it  could  only  be  passed  upwards  for  about  half  an 
inch.     A  thin  watery  mucus  in  small  quantities  was  discharged,  but  no  fasces 
or  urine.     Subsequently  fscal  matter  escaped  from  the  orifice.     The  pro- 
truded mass  was  ligatured  and  removed  with  a  good  result.     This  condition 
is  due  no  doubt  to  persistence  of  the  vitelline  duct  in  the  proximal  part  of  the 
cord  and  its  conversion  into  intestine  ;  it  communicates  with  the  ileum  by 
means    of    Meckel's  diverticulum.     After   the  distal  part  of  the  cord  has 
become  detached  the  end  cicatrises,  and  a  prolapse  takes  place  of  the  whole 
thickness  of  the  tube  ;  hence  in  the  section  in  fig.  8  two  layers  of  mucous 
membrane  with  an  intervening  muscular  and  fibro-cellular  layer  are  seen. 
Such  cases  are  not  rare  ;  we  have  met  with  several,  in  which  the  '  protrusion ' 
was  not  so  large  as  in   the  above  case,   but   from    which   there   was  a  thin 
biliary  discharge.     A  section  after  excision  showed  traces  of  muscular  fibres 
and  columnar  epithelial  cells.     We  have  seen  a  similar  case  in  a  child  of  six 
years  old,  but  the  parents  declined  any  interference. 

Another  form  of  umbilical  fistula  is  that  due  to  persistence  of  the  urachus. 
In    such  cases,    sometimes  called   navel  urachus    fistulae,    urine  escapes 


Fig.  8, 


Section  of  lleo-umbilical  Diverticulum 
a,  central  canal  continuous  with  Meckel's  di 
verticulum  lined  with  villi  ;  b,  remains  of  vill 
of  the  everted  portion  of  mucous  membrane 
c,  tubular  glands  ;  d,  remains  of  muscular 
coats;  e,  section  of  blood-vessels  (x  4).  The 
muscularis  mucosae  layers  are  also  seen.  (Dr. 
Serra's  case.) 


32  The  Diseases  incident  to  Birth 

externally  at  the  umbilicus.  Sir  T.  Smith,  Mr.  Bryant,  Mr.  T.  Paget  and 
others  have  described  instances  of  this  deformity  which  may  sometimes  be 
cured  by  ligature.  An  imperfect  obliteration  of  the  urachus  may  also  give 
rise  to  the  formation  of  a  cyst  in  the  middle  line  of  the  abdomen  below  the 
umbilicus. 

The  treatment  of  these  affections  is  very  simple  :  for  the  larger  ones  a 
ligature  should  be  apphed  tightly  round  the  base,  and  the  mass  cut  short 
off;  the  smaller  ones  may  be  snipped  off  with  scissors  or  rubbed  down  with 
nitrate  of  silver,  or  dusted  over  for  a  few  days  with  powdered  nitrate  of  lead, 
which  we  have  found  an  effectual  remedy.  It  must  be  remembered  that 
there  is  considerable  variation  physiologically  in  the  process  of  separation 
of  the  cord  ;  in  weakly  children  it  falls  off  later  and  the  raw  surface  is  slower 
in  healing.  Where  the  cord  stump  is  projecting  it  is  liable  to  be  irritated 
by  friction  and  its  healing  is  slow  :  this  is  the  condition  described  as 
excoriation.  When  a  sort  of  '  mucous  surface '  remains  and  goes  on  dis- 
charging, the  so-called  Blennorrhag-ia  exists,  while  the  presence  of  a  thick 
consistent  film  on  the  surface  of  the  sore  has  been  described  as  croupous 
or  diphtheritic  exudation  ;  in  some  instances  it  is  probable  that  a  true 
diphtheritic  membrane  is  formed. 

Where  there  is  any  spreading  ulceration  after  separation  of  the  cord, 
infective  influences  should  be  looked  for  ;  the  mischief  may  spread  super- 
ficially or  it  may  tend  inwards  and  involve  the  peritoneum.  A  mere  super- 
ficial excoriation  of  the  skin  analogous  to  intertrigo  elsewhere  is  often  seen 
in  older  children  as  a  result  of  dirt  and  neglect.  It  is  readily  cured  by  the 
application  of  boric  powder. 

Simple  ulceration  is  never  fatal  unless  it  extends  deeply  ;  it  should  be 
treated  by  some  simple  antiseptic  powder  or  ointment,  such  as  boric  acid 
or  iodoform. 

Omphalitis  is  a  rare  condition.  When  it  exists  the  navel  itself  and  the 
surrounding  parts  are  inflamed  and  swollen,  the  wound  remains  unhealed, 
and  the  skin  around  is  red,  shiny,  tense,  and  painful.  The  disease  may 
spread  and  involve  nearly  the  whole  of  the  abdomen  either  superficially  or 
throughout  the  entire  thickness  of  the  abdominal  wall ;  the  infant  becomes 
very  ill,  the  legs  are  stiff  and  drawn  up,  breathing"  is  thoracic,  and  small 
abscesses  may  form  and  burst  from  time  to  time.  The  disease  begins  in  the 
second  or  third  week  of  life,  and  may  last  for  some  days  or  even  weeks. 
The  prognosis  is  good  if  the  extent  of  mischief  is  small  and  suppuration 
occurs  early,  bad  if  the  disease  is  widespread,  and  especially  if  it  tends 
inwards  towards  the  peritoneum  ;  if  the  navel  vessels  are  involved,  general 
sepsis  or  gangrene  is  likely  to  result.  The  younger  the  child  the  greater  is 
the  danger. 

The  cause  of  this  disease  is  doubtful.  Probably  it  arises  from  bad 
management  of  the  navel  and  infection.  Fribe  believes  some  cases  to  be 
syphilitic.  Is  it  possible  that  some  may  be  instances  of  sloughing  phage- 
dfena  ?  According  to  Bouchut  it  is  sometimes  complicated  by  bleeding. 
Treatment  consists  in  cleanliness  and  the  application  of  antiseptic  or  seda- 
tive lotions.  All  abscesses  should  be  opened  early,  and  any  tendency  to 
gangrene  met  with  stimulants  and  antiseptics. 

Gang'rene  of  the  navel  begins  either  as  an  ulcer  or  as  omphalitis  ;  it 


Gangrene  3  3 

occurs  also  in  cases  of  cholera  infantum  ;  as  a  purely  local  condition  it  is 
rare,  and  Wiederhofer  believes  that  it  arises  from  intense  omphalitis.  Pre- 
mature separation  of  the  cord  and  irritation  tend  to  produce  gangrene. 

The  disease  usually  begins  as  a  blister  containing  muddy  fluid  ;  on 
bursting  this  leaves  an  ulcer,  or  a  sore  may  exist  from  the  first  ;  the  mischief 
spreads  rapidly  either  superficially  or  deeply  ;  a  bright  red  zone  is  seen  sur- 
rounding a  central  slough,  which  after  a  time  comes  away  ;  there  is  rapid 
prostration  of  strength,  though  but  little  pyrexia.  Recovery  from  gangrene 
of  the  navel  is  rare,  though  sometimes  the  slough  separates  and  the  cavity 
granulates  up  ;  more  often  death  results  from  peritonitis  or  exhaustion,  or 
again  from  gangrene  of  the  bowel  and  perforation,  which  is  sometimes  met 
with  ;  occasionally  a  fa.'cal  fistula  is  formed.'  In  many  cases  general  sepsis 
occurs,  and  Ritter  believes  the  gangrene  is  merely  a  result  of  the  septic  con- 
dition. In  cholera  infantum  there  is  sometimes  rapid  gangrene  without  any 
sign  of  reaction,  and  this  may  occur  as  late  as  several  months  after  birth  ;  it 
is  always  fatal. 

The  treatment  of  gangrene  consists  in  free  stimulation  and  the  use  of 
antiseptics  ;  nitrate  of  silver,  perchloride  of  iron,  and  salicylic  acid  are  recom- 
mended by  Runge,  to  whose  work,  'Die  Krankheiten  der  ersten  Lebenstage, 
we  are  indebted  for  nearly  all  our  information  on  these  diseases.  Faecal 
fistula,  if  the  child  survives,  should  be  treated  as  in  older  children. 

Umbilical  Arteritis. — In  fifty-five  subjects  of  disease  of  the  umbilical 
vessels  Runge  found  fifty-four  cases  of  arteritis,  and  in  only  one  was  there 
phlebitis  alone.  The  mischief  begins  as  inflammation  of  the  cellular  tissue 
round  the  vessels,  and  then  spreads  to  them,  producing  thrombosis.  Pelvic 
cellulitis,  which  sometimes  occurs,  is  the  result  of  septic  lymphangitis 
spreading  directly  along  the  cellular  tissue,  and  is  not  due  to  embolism. 
Inflammation  in  cases  of  arteritis  may  spread  far  and  wide  from  the  navel, 
and  even  reach  the  bladder  or  its  neighbourhood.  Where  arteritis  exists 
the  navel  often  presents  a  projecting  discoloured  ulcer  covered  with  a  scab  ; 
sometimes,  however,  the  scar  is  healed  and  quite  natural  in  appearance. 
The  disease  may  arise  either  before  or  after  separation  of  the  cord,  and 
suppuration  and  sloughing  may  occur. 

Sometimes  the  lumen  of  the  arteries  is  seen  open,  and  the  vessels  are  full 
of  pus  or  breaking-down  clot  ;  suppuration  usually  spreads  along  the  vessels 
as  far  as  the  cellulitis  extends,  beyond  this  adherent  coagula  are  found.  At 
times  the  arteries  are  pouched,  and  the  sacs  formed  are  found  full  of  pus  ; 
the  intima  of  the  vessels  is  always  dull  and  has  lost  its  polish. 

The  most  common  complication  of  the  disease  is  pneumonia  ;  septic 
inflammatory  foci  may,  however,  also  occur  in  the  liver,  spleen,  kidneys, 
peritoneum,  bones,  and  joints,  &c.  Erysipelas  sometimes  attacks  the  part, 
and  slight  jaundice  is  common,  though  severe  jaundice  with  hepatitis  is  rare. 
Of  Runge's  fifty-five  cases,  in  nine  there  was  arteritis  alone,  in  sixteen  there 
were  complications,  such  as  syphilis,  'atrophy,'  cerebral  haemorrhage,  &c., 
and  in  the  remaining  thirty  cases  there  were  py^'^mic  lesions.  Peritonitis  is 
to  be  suspected  as  soon  as  distension  appears.  Tetanus  is  an  infrequent 
complication.  Arteritis  is  a  disease  of  dirt  and  neglect  ;  it  occurs  in 
epidemics,  and  is  often  associated  with  puerperal  fever  ;  it  may  be  inoculated 
•   In  one  remarkable  case  an  intussusception  occurred  through  a  faecal  fistula. 

D 


34  The  Diseases  incident  to  Birth 

by  the  lochia  or  decomposing  umbilical  cord,  and  has  been  found  associated 
with  ophthalmia  neonatorum.  It  usually  runs  a  rapid  course,  lasting  from 
four  to  eighteen  days,  and  is  especially  fatal  to  young  and  premature  children  ; 
in  older  infants  the  prognosis,  though  bad,  is  not  absolutely  so  ;  in  fatal 
cases  death  is  usually  sudden. 

Vmbilical  Phlebitis.—  As  already  pointed  out,  umbilical  phlebitis  is  a 
rare  disease. 

The  general  appearances  of  phlebitis  are  very  like  those  of  arteritis  :  there 
is  thickening  of  the  perivascular  tissue,  the  lumen  of  the  vein  is  diminished  ; 
it  is  tortuous  and  contains  pus  or  sanious  material,  the  intima  is  cloudy 
and  eroded.  Usually  the  whole  vein  as  far  as  the  liver  is  affected,  and  there 
may  be  hepatitis.  Peritonitis  and  intense  jaundice  are  both  common.  The 
etiology  of  the  disease  is  the  same  as  that  of  arteritis.  The  symptoms  of 
phlebitis  are  fever,  icterus,  altered  respiration,  inspiration  being  short,  ex- 
piration prolonged,  while  the  breathing  is  shallow,  frequent,  and  entirely 
thoracic  ;  the  upper  part  of  the  abdomen  is  tumid,  and  there  is  local  tender- 
ness, the  knees  are  drawn  up,  and  the  child  is  restless.  It  is  difficult  to  dia- 
gnose phlebitis  from  arteritis  ;  the  intense  icterus  in  the  former  is  the  most 
characteristic  feature.  The  disease  lasts  only  a  few  days,  and  is  always  fatal 
from  general  sepsis.  The  treatment  of  both  arteritis  and  phlebitis  consists 
in  the  application  of  salicylic  acid  or  other  antiseptic  and  the  use  of  stimulants 
and  free  nourishment,  together  with  great  cleanliness. 

These  diseases  appear  to  be  almost  unknown  in  this  country  at  the  pre- 
sent day,  judging  from  the  absence  of  any  literature,  but  they  are  likely  to  be 
met  with  in  dirty  quarters  of  large  towns. 

Vmbilical  Hsemorrhage  is  to  be  looked  upon  as  a  symptom  rather  than 
a  disease  in  itself;  it  is  met  with  in  the  shape  of  bleeding  from  the  umbilical 
vessels  themselves,  and  as  a  general  oozing  from  the  raw  navel  surface. 

Bleeding  from  the  vessels  may  occur  from  slipping  or  imperfect  tying  of 
the  ligature  round  the  cord  ;  as,  for  instance,  when  a  thin  ligature  cuts  into  the 
vessels.  Bleeding,  of  course,  by  no  means  necessarily  follows  slipping  of  the 
ligature,  or  even  failure  to  tie  the  cord  at  all.  The  aspirating  action  of  breath- 
ing prevents  any  haemorrhage  in  most  instances,  and  this  is  supplemented 
by  the  contraction  of  the  vessels  after  birth. 

Asphyxia  may,  however,  produce  some  escape  of  blood  as  the  vascular 
pressure  rises  in  slight  degrees  of  suffocation  :  in  other  instances  deficient 
muscular  contraction  appears  to  be  the  cause,  hence  bleeding  is  most  common 
in  premature  children  who  have  been  asphyxiated  or  whose  lungs  have  not  ex- 
panded. If  it  arises  from  imperfect  muscular  contraction  it  may  occur  some 
hours  after  birth  (Hofmann).  As  the  vessels  begin  to  contract  at  the  cord, 
and  the  obliteration  extends  towards  the  hypogastrium,  there  is  more  risk  of 
bleeding  if  the  cord  is  cut  very  short.  So,  too,  drying  up  of  the  cord  tends 
to  obliterate  the  vessels,  while  gangrene  and  swelling  tend  to  prevent  their 
closure.  Bleeding  may  also  occur  later  from  rough  handhng  of  the  navel 
and  separation  of  the  scab.  All  danger  from  this  form  of  haemorrhage  maybe 
prevented  by  tying  the  cord  firmly  with  a  broad  ligature  not  too  near  the 
abdominal  wall  ;  should  bleeding  occur,  pressure  or  the  application  of  astrin- 
gent powders,  a  fresh  ligature  or  acupressure  will  arrest  it. 

Idiopathic,  or  spontaneous  bleeding  so  called,  is  a  very  rare  occurrence. 


Umbilical  Hcsmorrhage  35 

and  its  etiology  is  obscure.  Cirandidier  collected  twenty-two  cases  from 
various  sources.  The  bleeding  usually  occurs  about  the  fifth  day,  just  after 
or  more  rarely  before  the  cord  comes  away,  the  blood  trickles  from  the 
surface  of  the  umbilicus,  and  not  from  any  distinct  vessel  ;  the  oozing  may 
be  continuous  or  intermittent.  The  subjects  of  the  affection  are  generally 
healthy  full-time  children  ;  there  is  often,  however,  slight  icterus  ;  in  other 
cases  there  is  some  intestinal  disturbance,  vomiting,  colic,  &c.,  with  deep 
icterus,  cyanosis,  and  drowsiness  before  the  bleeding  occurs  ;  in  any  case 
these  symptoms  appear  soon  afterwards.  Bleeding  not  seldom  comes  on 
from  the  stomach  or  intestines,  or  there  may  be  general  purpura,  and  some- 
times there  is  oedema  of  the  hands  and  feet  together  with  the  umbilical 
haemorrhage. 

The  great  difficulty  or  impossibility  of  stopping  the  flow  is  characteristic 
of  the  condition.  Most  of  the  cases  die  before  the  second  week  ;  the 
mortality  is  put  down  as  83  per  cent.  The  infant  usually  dies  comatose,  less 
often  in  convulsions. 

Umbilical  hgemorrhage  is  a  symptom  of  several  diseases  ;  probably  in  some 
cases,  as  we  have  already  pointed  out,  it  is  due  to  hemophilia  or  syphilis. 
Privation,  drink,  and  other  depressing  causes  acting  upon  the  mother  are 
also  assigned  as  reasons  for  it.  Septicsemia  and  '  fatty  degeneration  of  the 
newly  born'  are  causes  that  have  been  established  hy post-7nortein  evidence. 
The  blood  in  these  children  does  not  clot  readily.  It  is  said  to  be  a  com- 
moner disease  in  America  than  elsewhere. 

Pressure  by  various  means,  such  as  pads,  filling  the  navel  with  plaster  of 
Paris,  underpinning,  &c.,  maybe  tried  as  means  of  treatment  with  some  hope 
of  success  ;  caustics  and  astringents,  such  as  perchloride  of  iron,  do  not 
appear  to  be  of  much  use  ;  the  actual  cautery  has  succeeded.  Idiopathic 
bleeding  is  very  rarely  met  with.  FUrth  has,  however,  collected  records  of 
some  cases  ; '  it  is  sometimes  epidemic.  Weiss  has  31  cases  out  of  742 
children  in  one  year  at  Prague.- 

For  other  morbid  conditions  of  the  umbilicus,  see  '  Deformities  of  the 
Umbilicus.' 

Tetanus  Nascentium. — This  disease  is  almost  unknown  in  this  country 
at  the  present  day,  although  in  past  times,  when  less  attention  was  paid  to 
general  hygiene  in  lying-in  hospitals,  it  was  common,  and  sometimes  was 
the  largest  factor  in  infant  mortality  ;  it  was  also  frequent  at  one  time  amono- 
the  negro  population  in  America.  The  disease  is  identical  with  the  wound 
tetanus  of  adults,  and  is  caused  by  inoculation  of  the  navel  with  the  tetanus 
bacillus.  This  bacillus,  as  shown  by  Nicolaier,  is  constantly  present  in  the 
superficial  layers  of  the  earth,  and  it  gains  entrance  to  the  infant's  body  by 
dirty  dressings  applied  to  the  navel.  The  bacillus  multiplies  in  the  neigh- 
bourhood of  the  navel,  and  a  strychnine-like  poison  is  absorbed,  which 
gives  rise  to  the  muscular  spasms.  The  bacilli  may  be  detected  in  the  pus 
of  the  navel  wound,  and  if  the  pus  be  injected  into  mice  they  die  with 
tetanic  symptoms.  (Rosenbach,  Peiper.)  Tetanus  ('  nine-day  fits  ')  usually 
appears  in  the  first  two  weeks  of  life,  most  commonly  from  the  third  to 

'  Arch.  f.  Kinderh.  Band  v.  p.  305. 

-  For  further  details,  vide  a  paper  by  Dr.  Francis  Minot  in  the  America?;.  Jour,  of 
Med.  Sci.  Oct.  18^2. 


36  The  Diseases  incident  to  Birth 

the  tenth  day,  the  hmits,  according  to  West,  being  from  the  fifteenth  hour 
to  the  fifteenth  day.  The  symptoms  are  usually  acute,  the  earliest  being 
inability  to  suck  from  spasm  of  the  facial  and  jaw  muscles  (trismus)  ;  general 
contractions,  however,  soon  occur,  the  spasms  are  continuous,  but  increase 
in  violence  at  intervals  ;  in  most  cases  there  is  no  complete  relaxation.  The 
child  often  utters  a  peculiar  whining  cry,  and  there  is  well-marked  risus 
sardonicus  ;  the  maximum  rigidity  is  generally  reached  in  twelve  hours,  and 
the  child  dies  in  a  fit  or  becomes  comatose. 

The  spasms  are  increased  by  any  exposure  to  cold  and  by  noise  ;  emacia- 
tion is  very  rapid,  and  there  is  often  jaundice.  Death  usually  occurs  in  one 
or  two  days  ;  in  rare  cases  the  disease  is  chronic.  Hartigan  says  the  chronic 
form  begins  with  dysentery  and  coldness  and  pallor  of  the  skin  ;  hence  it  has 
been  called  '  white  lockjaw.'  It  is  attended  by  wasting  and  twitchings,  and 
was  described  by  Marion  Sims  as  '  Trismoid.'  Unlike  the  acute  form,  which 
always  occurs  within  the  first  month  of  life,  the  chronic  variety  may  appear 
at  any  time  within  six  months,  and  may  be  a  sequel  of  the  acute. 

The  disease  is  readily  recognised  by  the  spasms  and  general  rigidity. 

The  preventive  treatment  consists  in  the  most  rigid  cleanliness  in  dress- 
ing the  navel  and  the  removal  of  insanitary  conditions.  Opium,  chloral^ 
bromide  of  potassium,  cannabis  indica,  belladonna,  and  other  drugs  have 
been  occasionally  successful  ;  warm  baths  sometimes  relieve  the  spasms,  and 
spinal  icebags  are  worth  a  trial  ;  anaesthetics,  such  as  ether  and  chloroform, 
are  useful  to  relieve  pain  and  allow  the  child  to  be  fed,  but  none  of  these 
remedies  have  given  any  constant  good  result.  Further  details  of  the  disease 
and  references  will  be  found  in  the  works  of  Bouchut,  Meigs  and  Pepper, 
Peiper,^  Baginsky.'^ 

Sclerema  DTeonatorum. — This  rare  disease  is  practicallyunknown outside 
foundling  asylums  and  lying-in  institutions,  and  is  by  no  means  common 
under  any  circumstances.  The  chief  characteristics  of  the  disease  consist 
in  an  induration  of  the  skin  and  subcutaneous  tissues,  and  marked  wasting, 
with  an  abnormally  low  temperature.  The  infants  at  birth  may  present 
no  abnormality,  and  in  some  cases  at  least  are  plump  and  healthy-looking  ; 
within  a  few  days  of  their  birth  they  begin  to  waste,  the  temperature 
becomes  abnormally  low,  83°  to  86°  F.  in  the  rectum,  and  the  integuments 
become  hard  and  rigid  ;  the  change  usually  begins  in  the  lower  extremities 
and  spreads  upwards,  and  involves  the  trunk,  upper  extremities,  and  face. 
In  typical  instances  the  skin  is  of  a  dirty  yellow  colour,  its  surface  is  hard 
and  does  not  pit,  and  it  cannot  be  raised  from  the  subcutaneous  tissues.  The 
surface  of  the  body  has  a  cold  feel  almost  like  stone.  In  some  described  cases 
the  rigidity  of  skin  has  been  so  great  that  the  infant  could  be  lifted  by  the 
head  and  heels  like  a  rigid  body.  On  account  of  the  rigidity  of  the  skin  of  the 
face,  sucking  is  performed  with  difficulty,  and  the  infant  has  to  be  fed  with  a 
spoon.  The  prognosis  is  bad,  as  such  infants  almost  invariably  die  in  a  ^ew 
days.  In  a  typical  case  investigated  by  Dr.  W.  P.  Northrup,  of  New  York, 
the  microscopical  examination  of  the  skin  showed  nothing  abnormal.  In  a 
case  of  Dr.  J.  W.  Ballantyne's  there  was  an  increase  in  the  number  and  size 
of  the  connective-tissue   bundles   and   an    atrophy    of  the   adipose  tissue. 

'  Deuisches  Archly  fur  klinische  Medici/i,  Bd.  xlvii.  H.  i  u.  2. 
-  Berliner  klinische  Wochcnschrift,  No.  7,  1891. 


Sclerema  Nconatontiii  37 

Langer  attributes  the  rigidity  of  the  integuments  to  solidification  of  the  fatty 
tissues,  in  consequence  of  the  abnormally  low  temperature.  In  one  case, 
however,  reported  by  Dr.  A.  (i.  Barrs,  which  he  believes  to  have  been  of 
this  nature,  the  infant,  which  was  a  month  old  when  seen  by  him,  made  a 
good  recovery.  In  this  case  the  skin  over  the  buttocks  and  thighs  was  hard 
and  rigid,  and  could  not  be  raised  from  the  deeper  tissues.  But  it  appears 
to  have  been  red  and  shiny,  and  without  the  cold  feel  so  typical  of  the 
ordinary  cases  of  sclerema.  The  pathology  of  these  cases  is  ill  understood. 
It  has  been  suggested  with  much  plausibility  that  they  are  akin  to  myxcedema. 
W'e  have  seen  a  similar  case  in  a  girl  two  weeks  old,  in  which  the  tissues  of 
the  back  of  the  trunk,  arms,  and  legs  were  much  indurated,  red,  and  shiny. 
They  were  too  hard  to  pit  with  the  finger.  We  think  that  this  case,  as  also 
Dr.  Barrs's,  were  not  identical  in  nature  with  those  described  as  sclerema. 
We  unfortunately  lost  sight  of  our  case  ;  the  infant  was  otherwise  apparently 
healthy  and  thriving. 

(Edema  Neonatorum. — Weakly,  especially  premature,  infants  are  apt  to 
be  oedematous  at  birth,  or  become  so  soon  after.  An  oedematous  condition 
of  the  skin  and  subcutaneous  tissues  dififers  from  sclerema  in  that  the  former 
readily  pits  beneath  the  finger,  and  the  skin  is  more  or  less  smooth  and 
shiny.  It  is  obvious  that  cedema  may  be  present  in  many  different  condi- 
tions, and  it  does  not  in  itself  constitute  a  disease. 

Gonorrhoea!  Ophthalmia. — Though  hardly  within  the  scope  of  this  work, 
mention  ought  perhaps  to  be  made  of  the  danger  to  the  infant  of  infection 
by  gonorrhoeal  discharges  from  its  mother  at  birth  or  shortly  after.  The 
most  common  affection  is  that  of  the  eyes,  in  which  a  virulent  purulent 
ophthalmia  is  produced.  The  inflammation  rapidly  spreads  to  the  eyelids, 
and  involves  the  cornea,  speedily  causing  opacity,  and  if  allowed  to  run  its 
course  unchecked  ending  in  perforation  of  the  cornea,  with  escape  of  the 
contents  of  the  globe  and  complete  shrinking  of  the  eyeball.  Many  cases 
of  total  blindness  in  children  are  due  to  this  cause.  In  any  case  where  there 
is  a  suspicion  of  vaginal  discharge  from  the  mother,  an  antiseptic  douche 
should  be  carefully  used  before  the  birth  of  the  child,  and  immediately  after 
it  is  born  the  child's  eyes  should  be  examined  and  carefully  washed  out 
with  a  solution  of  perchloride  of  mercury  (1-4,000),  followed  by  a  douche  of 
boric  acid  lotion.  At  the  least  sign  of  any  inflammation  the  eyes  should  be 
washed  with  a  solution  of  sulphate  of  zinc  (2  grains-^j),  and  unless  the 
mischief  is  at  once  checked  a  solution  of  nitrate  of  silver  (10  grains-5J)  should 
be  employed  once  a  day,  washing  out  again  with  a  solution  of  salt  directly 
after  to  prevent  too  powerful  action  of  the  silver.  The  eyes  should  be  bathed 
every  hour  day  and  night  with  a  lotion  of  boric  acid,  and  the  silver  repeated 
if  necessary.  It  is  only  by  such  means  that  the  eyes  can  be  saved  in  severe 
cases.  The  utmost  care  must  of  course  be  taken  to  use  all  applications 
thoroughly  and  get  rid  of  every  particle  of  discharge,  as  well  as  to  avoid 
subsequent  reinfection.  For  infantile  gonorrhoeal  rheumatism,  vide  chapter 
on  'Diseases  of  the  Joints.' 


38  The  Hygiene  and  Diet  of  Infants  and  Children 


CHAPTER   III 

THE    HYGIENE   AND   DIET   OF    INFANTS   AND    CHILDREN 

Newly  Born  Infants. — One  of  the  first  cares  of  the  nurse  after  the  navel 
has  been  properly  attended  to  should  be  to  direct  her  attention  to  the 
infant's  eyes,  carefully  wiping  away,  by  means  of  a  soft  rag,  any  mucus  or 
vaginal  discharge  which  may  adher.e,  and  thoroughly  cleansing  the  eyelids 
with  warm  water.  This  is  a  matter  of  much  importance  and  should  never 
be  neglected,  for  if  conjunctivitis  or  a  purulent  ophthalmia  be  set  up,  much 
trouble  may  ensue  and  some  time  elapse  before  a  healthy  state  is  again 
attained,  and  the  risk  of  corneal  opacities  and  consequent  loss  of  sight  is  by 
no  means  small.  The  temperature  of  the  room  in  which  mother  and  infant 
are  should  be  maintained,  at  least  in  winter,  at  65°,  and  means  be  taken  to 
thoroughly  ventilate  it  without  producing  draughts. 

In  giving  the  infant  its  first  bath — necessary  on  account  of  the  slimy 
whitish  secretion  with  which  the  infant  is  covered— care  should  be  taken 
that  it  is  done  before  a  good  fire,  and  that  the  water  of  the  bath  is  not  too 
hot  ;  the  temperature  should  not  exceed  100°  F.,  for  the  infant's  skin  is 
tender  and  easily  damaged  by  prolonged  contact  with  warm  water.  The  surface 
of  the  infant  is  well  cleansed  with  flannel  and  soap  while  on  the  nurse's  lap  ; 
it  is  then  bathed,  all  soap  being  removed  in  the  bath.  This  cleansing 
operation  is  repeated  daily,  the  genital  organs  and  buttocks  requiring 
especial  care  on  account  of  their  becoming  fouled  by  contact  with  soiled 
diapers  ;  intertrigo  and  erythematous  eruptions  are  likely  to  arise  if  the 
greatest  cleanliness  is  not  practised.  Some  infants'  skins  are  far  more 
tender  than  others  and  liable  to  eczema,  and  require  constant  care  to  avoid 
irritation.  Care  should  be  taken  in  the  selection  of  a  soap  which  is  free 
from  excess  of  alkali,  such  as  the  best  class  of  pure  Castile  soaps,  all  excess 
being  removed  in  the  bath.  The  skin  should  be  carefully  dried  with  a  soft 
towel,  and  some  fine  dusting  powder  applied  to  the  folds  of  the  groin  and 
buttocks.  This  may  consist  of  finely  powdered  maize  or  oatmeal  mixed 
with  2  per  cent,  of  salicylic  acid,  5  per  cent,  of  boracic  acid  or  thymol,  to 
prevent  any  tendency  to  decomposition.  Pure  boracic  acid,  as  in  the 
'  Sanitary  rose  powder,'  answers  very  well,  and  as  it  is  soluble  in  water  is 
easily  removed  by  washing.  The  diapers  should  be  of  a  soft  and  absorbent 
material  ;  at  least  a  dozen  should  be  provided  for  use  during  the  twenty-four 
hours.  They  are  usually  made  of  '  swansdown  '  or  '  Turkey  towelling,'  but  by 
far  the  best  material  is  '  Gamgee '  or  '  Robinson '  tissue,  a  piece  being  cut 
in  a  triangular  shape,  and  the  edges  run.  These  are  more  absorbent  than 
the  ordinary  napkin,  and  can  be  burnt  when  soiled.  They  can  be  obtained, 
ready  made  under  the  name  of  '  knapkinettes.'  ^ 

•'  Southall,  Barclay,  &  Co. 


Newly  BortL  h/fmits  .  39 

During  the  first  week  a  flannel  binder  is  necessary  to  keep  the  dressings 
in  position,  biU  afterwards  binders  are  best  avoided  ;  at  least,  nothing  tight 
should  be  applied  round  the  abdomen  which  would  cause  discomfort  to  the 
child  by  compressing  the  abdominal  viscera.  A  knitted  Shetland  wool  belt 
is  much  preferable  to  the  ordinary  strip  of  flannel  which  is  stitched  or 
pinned.  The  cord  may  be  dressed  with  a  pad  of  wood  wool  wadding  or 
(".amgee  tissue. 

It  is  hardly  needful  to  say  that  a  cot  should  be  provided  for  the  infant 
with  a  firm  mattress  protected  by  a  waterproof  covering,  and  under  no 
circumstances  whatever  should  the  infant  be  allowed  to  sleep  in  bed  with  its 
parents  or  nurse  ;  fatal  accidents  through  suffocation  of  the  infant  beneath 
the  bedclothes  are  constantly  occurring  in  consequence  of  the  mother  falling- 
asleep  with  her  infant  in  bed  with  her. 

Clothing-. — All  the  clothing  should  be  loose,  and  as  far  as  possible  con- 
sist of  flannel  or  knitted  woollen  material,  so  arranged  that  the  infant  can 
be  readily  dressed  and  undressed.  The  common  tendency  is  to  load  the 
chest  and  body  with  too  great  an  amount  of  clothes  and  to  leave  the  arms 
and  legs  too  much  exposed.  For  the  latter,  long  loosely  fitting  woollen 
drawers  coming  to  the  waist  should  be  used,  carefully  protected  by  the  diapers 
from  being  wetted.' 

Infant  Feeding-  at  the  Breast. — The  natural  food  of  an  infant  is  the  milk 
from  the  breast  of  its  mother,  no  kind  of  food  being  thought  of  for  the  first 
eight  or  nine  months  of  its  life.  The  mother's  health  may  of  course  sooner 
or  later  interfere  with  the  performance  of  this  duty  to  her  mfant,  but  it  is  of 
great  importance  that  it  should  be  attempted,  if  for  only  a  few  weeks  or 
months,  for  to  undertake  the  artificial  feeding  of  an  infant  from  the  first  is  to 
expose  it  to  serious  risk. 

The  infant  should  be  put  to  the  breast  a  few  hours  after  birth,  after  the 
mother  has  somewhat  recovered  from  the  pains  and  fatigue  of  labour,  and 
has  had  some  sleep.  It  is  of  much  importance  that  both  mother  and  infant 
should  get  as  much  rest  at  night  as  possible,  and  if  the  infant  frequently 
wakes  crying,  every  means  should  be  taken  to  hush  it  off  to  sleep  again, 
and  for  this  a  little  sweetened  water  or  barley  water  may  be  used.  It  is  not 
unlikely  that  for  the  first  day  or  two,  especially  in  primiparas,  the  supplv  of 
milk  will  be  scanty  and  the  infant  will  hardly  get  its  full  supply  ;  but  tnis  is 
a  matter  of  little  importance,  and  it  is  well  not  to  overload  the  stomach  at  nrst, 
but  to  give  it  an  opportunity  of  gradually  accustoming  itself  to  its  new  function. 

On  the  other  hand,  some  recent  writers  (McLane,  Holt)  have  shown  that 
thirst  and  starvation  give  rise  to  a  febrile  condition  to  which  the  term  of 
Inanition  Pever  has  been  given.  In  some  cases  at  least  where  the  infant 
has  sucked  at  a  dry  breast  and  has  had  no  artificial  food  or  fluid  or  an  in- 
sufficient quantity,  the  temperature  rises  to  102-104  on  the  third  day,  less 
often  the  second.  The  infant  is  restless,  its  lips  and  skin  are  parched.  All 
the  symptoms  are  quickly  relieved  by  its  taking  freely  of  breast  milk,  or  fail- 
ing this  water  or  artificial  food.     A  temperature  of  106°  has  been  observed. 

From  the  very  first  it  is  of  importance  to  accustom  both  infant  and 
mother  to  regular  times  for  feeding.  After  the  first  two  days,  every  two  hours 
during  the  daytime  will  be  quite  often  enough  for  an  infant  of  average  weight 
1  See  Health  in  the  Nursery  (Longman  &  Co.). 


40  TJie  Hygiene  and  Diet  of  Infants  and  Children 

and  strength.  A  longer  interval  may  be  taken  in  the  night,  so  as  to  give  the 
mother  as  long  a  sleep  as  possible  ;  nine  or  ten  feedings  in  the  twenty-four 
hours  will  be  sufficient.  A  strong  newly  born  infant  empties  the  breasts  in 
about  fifteen  minutes,  and,  during  this  time,  takes  from  i  to  i^  oz.  of  milk,  the 
total  amount  taken  in  the  twenty-four  hours  during  the  first  week  being  lo 
to  12  oz.  The  infant's  stomach,  at  this  period,  being  only  capable  of  hold- 
ing about  i^  oz.  (see  fig.  i)  without  marked  distension,  too  rapid  filling  of 
the  stomach  with  fluid  is  very  likely  to  give  rise  to  vomiting.  It  is  there- 
fore of  importance  for  the  mother  to  feed  the  infant  slowly,  extending  the 
time  to  fifteen  or  twenty  minutes.  We  must  not  forget  that  absorption  is 
going  on  during  the  time  the  infant  is  being  fed,  in  strong  and  vigorous  chil- 
dren, so  that  it  may  often  happen  that  such  will  take  more  than  the  above 
amounts  without  injury. 

The  infant's  stomach  rapidly  enlarges,  and  the  secretion  of  milk  increases 
as  time  goes  on  ;  so  that,  after  the  first  month,  eight  nursings  in  the  twenty- 
four  hours — that  is,  every  two  and  a  half  hours  during  the  day,  and  a  longer 
interval  at  night — will  be  enough.  From  the  end  of  the  third  month  till 
the  end  of  lactation,  every  three  hours  will  be  often  enough,  some  3  to  6  oz. 
being  taken  at  a  time,  and  some  20  to  40  oz.  in  the  twenty-four  hours. 
Six  to  seven  nursings  in  the  twenty-four  hours  will  be  sufficient. 

Too  frequent  nursing  is  bad  for  the  infant,  inasmuch  as  an  overworked 
stomach  cannot  properly  perform  its  .functions,  and  dyspepsia  is  only  too 
likely  to  result  ;  the  mother's  breasts  require  an  interval  of  rest,  for,  if  too 
frequently  drawn,  the  milk  is  apt  to  be  unequal  in  composition,  too  watery 
after  a  long,  and  too  rich  and  concentrated  after  a  short  interval. 

During  the  whole  time  the  infant  is  being  nursed  the  health  of  the  mother 
is  necessarily  a  question  of  the  greatest  importance,  as  it  is  impossible 
for  a  weakly  mother,  or  one  in  ill-health,  to  give  good  milk.  The  food  which 
she  takes  and  the  life  which  she  leads  are  all-impoiiant.  Anything  causing 
indigestion  in  the  mother  will  be  extremely  likely  to  affect  the  breast  milk 
and  disturb  the  infant's  digestive  organs. 

Various  drugs,  such  as  morphia  and  Epsom  salts,  when  taken  by  the 
mother,  are  excreted  in  the  milk,  and  may  of  course  affect  the  infant.  Any 
violent  emotion,  such  as  a  great  sorrow  or  any  prolonged  anxiety  suffered  by 
the  mother,  is  very  likely  to  alter  the  quality  of  the  milk,  and  the  infant  con- 
sequently suffers.  Indeed,  under  these  circumstances,  the  milk  may  cease 
to  be  secreted,  and  the  infant  have  to  be  artificially  fed.  The  mother's  diet 
should  consist  largely  of  milk,  porridge,  soups,  potatoes,  fish,  and  light  pud- 
dings, while  beef,  mutton,  and  stewed  fruit  should  be  taken  in  moderation 
She  should  avoid  all  highly  seasoned  foods,  and  those  difficult  to  digest,  such 
as  pastry,  raw  fruit,  and  uncooked  vegetables.  Alcoholic  liquors  are  unneces- 
sary, and  tea  and  coffee  should  be  taken  in  moderation.  Exercise  in  the  open 
air  is  of  the  greatest  importance,  but  it  must  be  graduated  accoi'ding  to 
the  strength  of  the  mother. 

Exercise  appears  to  tend  to  diminish  the  amount  of  proteids  in  the  milk, 
and  decreasing  the  amount  of  butcher's  meat  taken  will  tend  in  the  same 
direction.  Increasing  the  proteid  element  in  the  food,  assuming  that  the 
extra  proteid  food  is  digested,  renders  the  milk  richer  especially  as  regards 
the  fat. 


InftDit  Feeding  at  the  Jireast  41 

The  milk  of  the  first  few  clays  (colostrum)  differs  from  normal  milk  in 
that  it  is  of  a  yellowish  colour,  is  unusually  rich  in  proteids,  and  has  a  laxative 
effect  upon  the  infant's  bowels.  It  also  contains  less  sugar  than  normal  milk. 
Microscopically  a  number  of  granular  corpuscles  are  seen,  which  are  appa- 
rently epithelial  cells  undergoing  fatty  degeneration.  In  a  few  days  the  excess 
of  proteid  disappears,  but  it  may  be  a  week  or  more  before  the  milk  is  nor- 
mal. The  changes  which  occur  in  the  quality  of  the  milk  during  the  lacta- 
tion period  depend  very  largely  of  course  on  the  health  of  the  mother. 
During  the  later  months  of  lactation  the  milk  tends  to  become  poorer  and 
more  watery,  with  a  diminution  of  the  proteids  and  fat.  It  must  be  borne  in 
mind  how  completely  the  secretion  of  the  milk  is  under  the  influence  of  the 
nervous  system,  and  how,  also,  it  varies  from  time  to  time  from  various 
causes  ;  and  more  or  less  caution  must  be  observed  in  drawing  conclusions 
as  to  the  effect  of  any  one  cause  on  the  quality  of  the  milk. 

The  occurrence  of  menstruation  in  a  nursing  mother  or  wet  nurse  is  apt 
in  some  way  or  other  to  alter  the  secretion  of  the  milk,  and  the  infant,  in 
consequence,  may  suffer  from  colic,  flatulence,  or  diarrhoea.  In  many  cases 
the  infant  does  not  appear  to  suffer  at  all,  while  in  exceptional  cases  the 
intestinal  disturbance  and  loss  of  flesh  are  so  great  that  the  question  of  wean- 
ing may  have  to  be  entertained.  It  may  happen  that  the  infant  may  suffer 
a  good  deal  at  one  period  and  not  at  the  next  or  succeeding  ones.  The 
chemical  changes  which  occur  during  menstruation  have  been  investigated 
by  several  observers,  but  no  constant  change  has  been  found.  In  some 
cases  the  careful  observations  of  Rotch  have  shown  that  the  milk  during 
this  period  is  poorer  in  fat  and  richer  in  proteids,  but  it  is  tolerably  certain 
that  this  is  not  universally  the  case.  Monti  found  that  menstruation  exercised 
no  constant  change  or  influence  on  the  specific  gravity  or  the  fatty  elements, 
though  in  some  cases  observed  by  him  there  was  an  increase  in  the  quantity 
of  fat  during  the  period. 

■Wet  ITurses. —  It  not  infrequently  happens  that,  if  an  infant's  life  is  to  be 
saved,  a  wet  nurse  must  be  procured.  It  may  happen  that  a  weakly  infant 
is  deprived  of  its  mothers  milk,  and  a  foster  mother  must  be  obtained  if  its 
hfe  is  to  be  preserved.  In  some  cases,  perhaps,  an  attempt  has  been  made 
to  feed  a  young  infant  on  some  artificial  food,  various  foods  being  tried,  one 
after  another,  till  severe  convulsions  or  continuous  diarrhoea  warn  the 
attendants  that  a  return  to  the  infant's  natural  food  is  the  only  possible 
resource  left.  Much  has  been  written  about  the  advantages  and  dis- 
advantages of  a  wet  nurse.  We  may  say  at  once  that,  in  our  opinion,  there  is 
not  the  least  doubt  that  no  artificial  food  yet  devised  can  compare  with  or 
form  a  substitute  for  the  milk  of  a  healthy  woman.  To  attempt  to  bring  up 
a  weakly  infant  from  the  first  on  artificial  food  is  to  expose  it  to  far  more 
serious  risks  than  if  it  is  provided  with  a  healthy  wet  nurse.  The  younger 
the  infant  is,  the  more  likely  is  it  to  take  the  breast  milk  of  a  wet  nurse  and 
to  thrive  on  it,  or  in  other  words  the  value  of  a  wet  nurse  is  greatest  during 
the  first  few  weeks  of  an  infant's  life.  To  put  an  infant  of  three  or  four  months 
of  age  that  has  been  artificially  fed  to  the  breast  of  a  wet  nurse  is  likely 
enough  to  end  in  failure.  Unfortunately  in  this  country  wet  nurses  are 
difficult  to  obtain,  and  when  obtained  are  not  always  easy  to  manage  in  the 
household.     At  the  same  time,  we  are  inclined  to  think  that  the  character  of 


42  The  Hygiene  and  Diet  of  Infants  and  Children 

wet  nurses  as  a  class  has  often  been  painted  in  too  black  colours  ;  certainly 
we  have  known  many  who  have  done  their  duty  to  their  foster  infants  in  a 
most  worthy  and  exemplary  manner.  A  difficulty  often  is  presented  with 
regard  to  the  nurse's  own  child  ;  it  is  put  out  to  nurse,  and  is  deprived  not 
only  of  its  mother's  milk,  but  also  of  its  mother's  care,  and  is  only  too  likely 
to  go  the  way  that  so  many  '  out-to-nurse '  babies  have  gone  before.  In 
large  cities  wet  nurses  are  usually  obtained  at  the  workhouses,  where  many 
women  go  to  be  confined,  and  are  often  glad  to  escape  from  the  discipline  of 
the  workhouse,  and  to  obtain  a  situation  in  a  private  family  at  good  wages. 

A  wet  nurse  should  not  be  above  thirty-five  or  below  twenty-one  years 
of  age  ;  very  young  wet  nurses  are  especially  to  be  avoided,  on  account  of 
their  inexperience  and  the  difficulty  in  managing  them.  It  is  better  for  the 
nurse's  infant  to  be  a  month  or  so  older  than  the  infant  to  be  nursed.  Great 
disparity  of  age  is  an  objection,  as  a  nurse  who  has  been  confined  five  or  six 
months  before  is  not  Hkely  to  make  a  good  nurse  for  a  newly  born  infant,  at 
least  not  for  the  whole  time  that  the  infant  has  to  be  nursed  ;  but  such  a 
nurse  may  be  employed  temporarily  in  the  absence  of  a  more  suitable  one. 
A  disparity  of  two  or  three  months  is  no  objection,  provided  the  nurse  is 
suitable  in  other  ways.  A  medical  examination  of  the  nurse  should  always 
be  made — at  least,  the  medical  attendant  should  satisfy  himself  that  both 
the  nurse  and  her  infant  are  free  from  disease.  There  is  one  advantage  in 
the  nurse's  infant  being  two  or  three  months  old,  and  that  is  that  time 
would  have  been  afforded  for  any  syphilitic  rash  to  make  its  appearance  on 
the  infant,  and  the  infant  if  strong  and  vigorous  is  reliable  evidence  of  the 
good  quality  of  the  milk.  If  possible,  an  analysis  of  her  milk  should  be 
made  upon  several  occasions,  especially  with  regard  to  the  amount  of  fat 
present  in  the  milk.  But,  in  spite  of  all  precautions,  we  must  be  prepared 
at  times  to  find  that  the  milk  of  a  wet  nurse  who  in  every  way  appears 
suitable  does  not  agree  with  the  infant,  and  the  only  resource  is  to  try  another. 
Great  pains  must  be  taken  in  the  dieting  of  the  nurse,  errors  being  most  fre- 
quent in  the  direction  of  overfeeding  with  too  little  exercise.  Meat  once  a 
day  is  enough,  beer  and  porter  are  best  avoided,  and  exercise  in  the  open 
air  must  be  insisted  on. 

No  infant  suffering  from  hereditary  syphilis  should  be  wet-nursed,  on 
account  of  the  risk  of  its  infecting  its  foster  mother. 

"Weaning-. — The  length  of  time  during  which  the  infant  takes  its  sole, 
nourishment  from  its  mothei-'s  breast  depends  upon  a  variety  of  circum- 
stances. When  the  mother  remains  strong  and  healthy  and  has  a  sufficient 
supply,  the  time  may  be  extended  to  eight  or  nine  months,  or  even  more. 
Among  the  working  classes  the  time  is  often  extended  much  longer  than 
this.  Infants  who  are  over-nursed  are  apt  to  be  fat,  but  are  not  necessarily 
strong — indeed,  they  often  appear  rickety  in  a  minor  degree.  In  a  case  re- 
cently coming  under  our  notice,  the  mother  nursed  her  infant  entirely  at  the 
breast  for  seventeen  months.  The  child  weighed  twenty  pounds,  it  showed 
signs  of  rickets,  the  epiphyses  being  moderately  enlarged  and  the  ribs 
beaded.  An  examination  of  the  mother's  milk,  which  was  plentiful,  showed 
it  was  poor — the  amount  of  fat  (average  of  three  samples)  17  per  cent.  ;  the 
specific  gravity  was  1031. 

Whenever  weaning  takes  place  it  is  wise  to  do  it  gradually,  in  the  first 


Weaning 


43 


place  substituting  the  bottle  for  the  breast  once  or  twice  in  the  twenty-four 
hours,  and  carefully  watching  the  result  before  attempting  more  than  this. 
Gradually  artificial  feeding  may  be  made  to  take  the  place  of  the  breast  en- 
tirely. It  is  well  to  avoid  the  hottest  weather  for  this  change  on  account  of 
the  risks  of  diarrhoea  at  this  time. 

.At  any  time  during  the  period  of  lactation  it  may  be  necessary,  on 
account  of  the  mother's  health,  to  supplement  nursing-  with  other  food,  or  to 
give  up  nursing  altogether.  The  question  of  whether  to  give  up  nursing  or 
not  is  often  a  difficult  one  to  decide.  If  the  mother  is  suffering  from  any 
organic  disease,  there  cannot  be  any  doubt  as  to  giving  up  nursing  both  for 
her  own  sake  and  that  of  the  infant.  It  may  happen  that  the  breast  milk 
entirely  goes,  and  either  a  wet  nurse  must  be  obtained  or  artificial  food  be 
substituted  ;  in  other  cases  the  decision  is  much  more  difficult  ;  the  infant  does 
not  appear  to  thrive,  and  the  fault  may  be  in  the  quality  of  the  mother's  milk. 

Much  useful  information  may  be  gained  by  weighing  the  infant  every 
week  ;  a  regular  gain  of  5  to  6  ounces  a  week  during  the  first  three  or  four 
and  3  to  4  ounces  from  the  third  to  the  sixth  month  will  indicate  that  the 
infant  is  thriving  in  spite  of  some  minor  troubles  it  may  be  subject  to.  It 
must  be  remembered,  however,  that  the  infant  may  put  on  fat  without  a  cor- 
responding development  in  the  other  tissues. 

Valuable  information  may  be  obtained  by  an  examination  of  the  breast 
milk  ;  unfortunately,  no  mere  inspection  or  microscopical  examination  is  of 
any  use  :  an  analysis  must  be  made  by  a  competent  chemist  by  ordinary 
methods,  or  approximate  results  may  be  attained  by  the  estimation  of  fat  by 
means  of  the  acid  butyrometer  (see  Appendix).  Care  should  be  exercised  to 
see  that  the  milk  taken  for  analysis  is  the  middle  portion  :  that  is,  the  infant 
should  be  put  to  the  breast  for  five  minutes  or  more,  and  then  ^-i  oz.  drawn 
from  the  same  breast  by  means  of  a  breast  pump.  This  will  give  a  fair  sample 
of  the  milk.  The  two  most  important  considerations,  as  Rotch  points  out, 
are  the  amount  of  fat  and  the  amount  of  proteids  present.  A  low  proportion 
of  fat  and  a  high  proportion  of  proteids  indicate  a  bad  milk. 

The  following  analyses  represent  examples  of  human  milk  of  different 
qualities  (Rotch)  : 


Normal 

Poor 

Over-rich 

Bad 

Fat 

Proteids      .... 
Lactose       .... 
Ash 

Total  solids 

Water         .... 

4 
1-2 

7 

0-2 

1-50 
2-40 
4-00 
0-09 

5-IO 
3'5o 
7-50 
0-25 

o-8o 
4-50 
5-00 
0-09 

12-13 
88-87 

7-99 
92-01 

16-35      1       10-39 
83-65            89-61 

100- ICO 

1 00 -CO 

loo-oo 

1 00-00 

If  the  mother's  milk  is  poor,  an  attempt  may  be  made  to  improve  it  by 
prescribing  a  diet  containing  more  meat  and  some  alcohol  for  the  mother.  A 
change  to  the  seaside  is  often  of  value.     The  infant  may  be  taken  at  night 


44  The  Hygiene  and  Diet  of  Infants  and  Children 

by  the  nurse  and  given  one  or  two  bottles  of  milk  and  water,  so  as  to  give 
the  mother  complete  rest  at  night. 

Artificial  Feeding'. 

The  most  convenient  substitute  for  human  milk  is  the  milk  of  the  cow. 
The  milk  of  some  other  animals,  such  as  the  goat,  ass,  mare,  has  been  used 
with  more  or  less  advantage,  but  cow's  milk  is  likely  to  remain  the  all  but 
universal  substitute.  Goat's  milk  has  one  or  two  practical  advantages  ;  in 
the  first  place,  the  goat  appears  rarely  to  suffer  from  tuberculosis,  an  immunity 
which  it  owes  to  its  outdoor  life,  while  the  cow  is  known  to  be  very  fre- 
quently affected  with  this  disease  ;  and  in  the  second  place,  for  a  family  in 
the  country  having  their  own  grass  plot,  it  may  be  often  very  convenient  to 
purchase  a  milch  goat  and  fodder  it  at  home.  A  milch  goat  is  of  course 
much  cheaper  than  a  cow,  and  can  be  kept  at  practically  no  expense.  The 
chemical  differences  between  the  milk  of  the  cow  and  that  of  the  goat  are 
not  great,  and  there  is  no  advantage  except  that  already  mentioned  in  sub- 
stituting goat's  milk  for  cow's  milk. 

The  milk  of  the  ass  much  more  nearly  resembles  human  milk  than  either 
the  milk  of  the  cow  or  goat.  Unfortunately  ass's  milk  is  difficult  to  obtain 
in  this  country,  and  is  also  costly. 

Cow's  Milk. — The  milk  of  the  cow  has  been  studied  more  closely  than 
the  milk  of  any  other  animal,  on  account  of  its  great  importance  to  the  com- 
munity as  an  article  of  commerce.  As  a  food  its  importance  is  derived  fiom 
the  fact  that  it  supplies  in  due  proportion  proteids,  carbo-hydrates,  hydro- 
carbons, salts  and  water,  while  it  contains  no  waste  products,  and,  moreover, 
it  is  digested  with  comparative  ease.  It  requires  when  fresh  and  pure  no 
preparation  to  render  it  fit  for  consumption. 

The  richness  of  milk  is  influenced  in  various  ways — the  materials  with 
which  the  cows  are  fed,  the  length  of  time  during  which  they  have  been  in 
milk,  and  also  by  the  breed.  The  milk  supplied  at  our  doors,  it  is  needless 
to  say,  varies  with  the  honesty  of  the  purveyor  and  the  cleanliness  observed 
in  its  collection  and  transit. 

A  superstitious  belief  in  the  superior  virtues  of  the  milk  of  '  one  cow '  is 
still  common  among  the  public,  and  it  is  often  looked  upon  as  a  most 
important  matter  to  secure  this.  As  a  matter  of  fact,  a  good  average  milk  is 
more  likely  to  be  obtained  from  mixing  the  milk  of  a  manher  of  cows  than 
in  taking  it  from  one,  for  it  is  well  known  that  the  first  portion  of  milk 
obtained  from  the  udder  is  poor  in  fat,  while  the  last  portions  are  rich,  the 
amount  of  fat  varying  from  2  to  8  per  cent.  If  the  first  part  of  the  milk 
taken  is  reserved  for  an  infant,  it  is  tolerably  certain  to  get  a  poor  milk. 
Whenever  a  cow  is  specially  reserved  to  supply  milk  for  an  infant,  care 
should  be  taken  to  see  that  it  is  sound  and  healthy.  It  should  be  tested 
with  tuberculin  by  a  competent  veterinary  surgeon. 

What  is  of  far  more  importance  than  the  question  of  '  one  cow '  is  the 
question  as  to  the  health  of  the  cows,  and  how  they  are  fed,  and  the  care 
taken  to  prevent  the  contamination  of  the  milk  with  organic  matters.  In 
the  vicinity  of  our  large  towns  it  is  no  uncommon  thing  to  see  cows  out  at 
pasture  in  fields  watered  by  brooks  contaminated  with  sewage,  of  which  they 
freely  drink  ;  moreover,  they  are  extremely  likely  to  lie  down  in  the  sewage 


Coiv's  Milk 


45 


water,  and  their  udders,  and  consequently  the  milker's  hands,  become 
befouled  with  sewage.  In  the  winter  time  the  cows  are  frequently  fed 
largely  on  turnips  and  brewer's  grains,  instead  of  hay,  maize,  or  other  dry 
fodder  :  possibly  also  their  sheds  are  infrecjuently  cleaned  out  and  only 
sparingly  supplied  with  straw,  so  that  the  animals  lie  in  faeces,  and  their 
udders  may  be  seen  caked  with  dried  excrement.  It  is  no  uncommon  thing 
to  find  a  greenish-looking  sediment  in  milk  from  second-rate  dairies,  due  to 
contamination  of  faecal  matters.'  The  storage  of  milk  is  an  exceedingly 
important  matter  ;  it  is  readily  contaminated  when  kept  in  cellars  or 
kitchens  pervaded  with  sewer  gas  or  the  emanations  of  decomposing  animal 
substances.  The  temperature  at  which  it  is  kept  is  also  important,  as 
it  far  more  quickly  turns  sour  and  decomposes  when  kept  in  a  warm  place 
than  in  a  cool  place.  This  is  recognised  by  many  milk  purveyors,  who 
take  measures  to  cool  the  milk  directly  it  is  received  from  the  cow  by 
means  of  iced  water.  The  day's  supply  of  milk  for  the  household  or  for  the 
children  should  never  be  kept  in  the  nursery  or  kitchen,  but  should  be 
covered  and  kept  in  cool,  well-ventilated  cellars,  or  out  of  doors  in  the  shade. 
According  to  Soxhlet  fresh  milk  turns  sour  and  curdles  at  the  following 
temperatures  and  times  : 

At  32°  C.  (90°  F.)  in  19  hours         At  17^  C.  (63-5°  F.)  in  63  hours- 
At  25°  C.  {^f  F.)  in  20  hours         At  10°  C.  (40°  F.)  in  208  hours 
At  0°  C.  (32°  F.)  in  3  weeks. 

Freeman  has  shown  by  experiment  the  effect  of  temperature  on  the  growth 
of  bacteria  in  milk.  Samples  of  the  same  milk  were  kept  at  different  tempera- 
tures for  twenty-four  hours,  and  the  number  of  bacteria  estimated  in  a  fixed 
amount  of  each  specimen.  The  one  kept  at  45°  F.  had  445  ;  that  at  50°  F. 
[,362  ;  that  at  55°  F.  67,170  ;  while  that  at  68°  F.  had  the  enormous  number 
of  134,340. 

We  give  here  three  different  analyses  of  cow's  milk  :  (I)  a  good  average 
specimen  according  to  Leeds  ;  (II)  a  pure  milk  according  to  Langlois  ; 
(III)  an  average  specimen  as  supplied  by  the  milkmen  of  Paris  (Langlois)  : 


I. 

10297 

II. 

III. 

'^^33 

77 

Specific  gravity .... 
Vol.  of  cream     .... 

10317 
10 

Fat 

Lactose      ..... 

1  Proteids 

Ash 

Total  solids        .... 

375 
4-42 

376 
•68 

4 
5 

3-4 
•6 

3-34 

4-92 
3-4 

•57 

I2-6l 

13-0 

12-23 

The   rat    of  milk    consists    principally  of  margarine  and  oleine  ;  it  is 
present  in  milk  as  minute  globules,  which  on  standing  rise  to  the  surface  in 

'  The  bacillus  coli  communis  is  constantly  found  in  ordinary  milk,  in  consequence  of 
fascal  contaminations.     See  B7-it.  Med.  Journal,  August  31,  1895,  p.  544. 
-  Temperature  of  ordinary  kitchen. 


46  The  Hygiene  and  Diet  of  Infants  and  Children 

the  form  of  cream.  A  microscopical  examination  of  a  drop  of  milk  displays 
these  minute  globules  of  fat,  and  also  colostric  corpuscles  and  fatty 
epithelial  cells  if  the  animal  has  recently  calved.  According  to  some  the 
fatty  globules  are  surrounded  by  an  albuminous  envelope  ;  others  believe 
milk  to  be  really  an  emulsion,  in  which  the  fatty  particles  are  held  in 
suspension  by  the  albumen  and  caseinogen  in  the  milk.  The  fat  can  be 
extracted  by  shaking  with  ether,  after  the  addition  of  a  drop  or  two  of  a 
solution  of  caustic  potash.  If  milk  be  long  heated  at  100°  C.  or  at  a  higher 
temperature,  the  emulsion  is  in  part  interfered  with,  and  globules  of  butter 
oil  will  rise  to  the  top  if  the  milk  is  warmed  ;  a  microscopical  examination 
of  such  milk  shows  the  fatty  globules  to  have  in  part  run  together. 

The  Kactose  or  IVIilk  Sug-ar  is  the  member  of  the  carbo-hydrate  group 
present  in  milk,  and  is  destined  to  be  converted  into  glucose,  and  in  this 
state  enters  the  blood  of  the  portal  vein.  It  is  readily  converted  into  lactic 
acid  in  the  stomach  and  intestines.  It  is  uncertain  if  lactic  acid  is  present 
in  normal  digestion  in  the  stomach,  but  in  some  forms  of  dyspepsia 
excessive  quantities  are  formed,  so  that  some  infanta  who  are  suffering  from 
chronic  dyspepsia  have  a  strong  'sour  milk'  odour.  Possibly  this  rancid 
smell  may  be  due  in  part  to  butyric  acid.  Lactic  acid  may  be  decomposed 
into  alcohol  and  carbonic  acid,  and  also  into  butyric  acid  and  carbonic  acid. 
The  latter  two  processes  probably  only  take  place  in  abnormal  digestion. 

The  Proteids  of  milk  are  two  in  number — caseinogen  and  lactalbumen 
(Halliburton).  In  cow's  milk  the  former  is  present  in  much  larger  quantities 
than  the  latter,  the  reverse  holding  good  in  woman's  and  ass's  milk. 
Caseinogen  is  precipitated  by  acetic  acid  or  by  saturating  with  a  neutral  salt 
such  as  sulphate  of  magnesia  ;  lactalbumen  is  coagulated  on  boiling. 
Lactalbumen  closely  resembles  serum  albumen,  but  it  coagulates  at  a  some- 
what higher  temperature,  T]°  C.  (Halliburton).  It  only  slowly  coagulates  at 
this  temperature,  and  even  at  a  higher  temperature  some  time  is  required  to 
fully  coagulate  it.  If  rennet  be  added  to  cow's  milk  the  caseinogen  is 
decomposed  into  casein  or  curd  of  milk,  which  is  precipitated  in  dense  flakes, 
and  a  second  proteid,  the  '  whey  proteid  '  which  remains  in  solution.  The 
presence  of  lime  salts  is  necessary  for  this  change  to  take  place  (Hammarsten). 
'  Whey  proteid'  is  not  precipitated  by  heat. 

The  curd  of  cow's  milk  forms  a  dense  heavy,  lumpy  precipitate  in  the 
stomach,  differing  very  markedly  from  the  soft  flocculent  precipitate  from 
woman's  milk.  It  is  attacked  with  difficulty  by  the  gastric  juice,  and  a  large 
proportion  of  it  passes  into  the  intestines  practically  unchanged. 

The  Salts  of  milk  consist  of  potash,  lime,  and  soda  in  combination  with 
phosphoric  acid  and  chlorine. 

-Woman's  l«ilk. — The  following  figures,  according  to  Leeds,  represent 
the  principal  differences  between  cow's  and  woman's  milk  : 

Sound  dairy  milk  Average  woman's  milk 

Reaction        .         .         .     acid  alkaline 


Specific  gravity 

Fat 

Lactose. 

Proteids 

Ash 

Bacteria 


1029  1031 

■      375  4-13 

.      4-42  7 

.      376  2 

•68  -2 

numerous  absent 


lVo;/u7u's  Milk 


47 


We  have  taken  the  analyses  of  Professor  Leeds  of  woman's  milk  as  beiny 
llie  average  of  a  large  number  of  specimens,  but  the  variations  in  different 
samples  is  very  considerable.  The  analyses  g-iven  by  different  authorities 
also  differ  considerably,  as  the  following  table  will  show. 

Woi/iati's   Milk 


- 

Solids 

Proteids 

Fat 

Lactose 

Salts 

Pfeiffer      . 

I  I  778 

1-944 

3-107 

6-303 

-192 

Hoffmann 

12-340 

I  -030 

4-070 

7-030 

-210 

Leeds 

13-268 

1-995 

4-131 

6-936 

-201 

Luff  . 

I  I  -490 

2-350 

2-410 

6-390 

-340 

Adriance  . 

12 

1-2 

3-4 

6-7 

•20 

Colostrum 

Pfeiffer      . 

157 

9-756 

2-954 

2-942 

•408 

The  principal  points  to  be  noted  are  the  following  :  (i)  the  excess  of 
proteids  in  cow's  milk,  and  the  excess  of  curd  (caseinogen)  over  lactalbumen 
as  compared  with  woman's  milk.  According  to  Hirt,  the  amount  of  curd  in 
cow's  milk  is  3  per  cent,  (lactalbumen  -75  per  cent.),  in  woman's  milk  it  is 
only  -63  per  cent,  (lactalbumen  1-5  per  cent.),  so  that  the  amount  of  curd  is 
nearly  five  times  as  great  in  the  former  as  in  the  latter.  (2)  Smaller  quantity 
of  lactose  in  cow's  milk.  (3)  The  fat  is  about  the  same.  (4)  The  ash  is 
greater  in  cow's  milk.  (5)  By  the  time  the  cow's  milk  reaches  the  consumer 
it  is  slightly  acid  and  contains  numerous  bacteria,  while  woman's  milk  is 
supplied  direct  to  the  infant,  and  is  alkaline  and  sterile. 

In  substituting  cow's  milk  for  human  milk,  we  necessarily  endeavour  to 
imitate  the  latter  as  much  as  possible.  The  great  difficulty  to  be  overcome 
is  the  large  quantity  and  solidity  of  the  curd  which  is  thrown  down  in  cow's 
milk  when  the  latter  comes  in  contact  with  the  curdling  ferment  of  the 
infant's  stomach.  Woman's  milk  curdles  in  soft  flakes,  which  hardly  offer 
any  resistance  when  pressed  between  the  finger  and  thumb,  while  the  curd 
of  cow's  milk,  especially  if  the  curdling  has  been  rapid,  consists  of  firm 
cheesy  lumps.  The  digestive  juices  of  the  infant's  stomach  and  intestines 
are  unable  to  dissolve  these  lumps,  and,  if  not  vomited,  they  partially 
decompose  under  the  influence  of  the  bacteria  they  contain,  gases  and 
ptomaines  are  formed,  and  much  discomfort  and  perhaps  diarrhoea  or 
convulsions  take  place  before  the  decomposing  curd  is  passed  in  the  stools. 
Any  one  who  has  had  an  opportunity  of  carefully  watching  the  effects  of 
cow's  milk  when  taken  by  an  infant  a  few  days  old,  and  noted  the  effect  if 
the  milk  of  a  wet  nurse  is  substituted  for  cow's  milk,  will  see  at  once  the 
difference  in  the  quality  of  the  stools,  and  the  immediate  cessation  of  the 
discomfort  and  indigestion  which  the  infant  is  certain  to  have  suffered  when 
taking  the  cow's  milk.  The  difficulty  with  regard  to  the  curd  can  partly  be 
got  over  by  diluting-  and  peptonising  or  adding  malt  extract,  but  no  method 
has  been  discovered  by  which  cow's  milk  can  be  rendered  as  digestible  and 


48 


TJlc  Hygiene  and  Diet  of  Infants  and  Children 


nutritive  as  woman's  milk.  The  curd  thrown  down  from  condensed  milk, 
or  milk  which  has  been  desiccated,  appears  to  digest  more  readily  and  with 
less  discomfort  than  the  curd  of  fresh  cow's  milk. 

IVXodified  Milk.  Humanised  IWilk.  Cream  BSixtures. — The  readiest 
way  to  prepare  an  infant's  food  from  cow's  milk  is  to  dilute  with  water  and 
add  sugar.  It  is  plain,  however,  that  while  the  resulting  mixture  if  suffi- 
ciently diluted  may  be  suited  to  the  infant's  digestion  as  far  as  the  proteids 
are  concerned,  it  will  certainly  be  deficient  in  fat,  and  will  not  be  a  good 
copy  of  human  milk.  On  the  other  hand,  if  only  a  small  proportion  of 
water  is  added,  the  mixture  will  contain  a  too  high  proportion  of  the  proteids. 
This  is  seen  in  the  table. 


Proteids 

Fat 

Sugar 

Human  milk      .... 

1-2 

3-4 

6-7 

Cow's  milk         .... 

375 

375 

4 

Cow's  milk  2  ) 

Water  i         ^     •         •         •         • 

2-5 

2-5 

2-7 

Cow's  milk  i  , 

Water  i          j     •         •         •         • 

1-87 

1-87 

2 

Cow's  milk  i  i 
Water  2         )      ■         ' 

1-25 

1-25 

1-3 

What  must  be  aimed  at  is  a  mixture  containing  the  various  constituents 
in  the  proportion  of  an  average  example  of  human  milk. 

It  must,  however,  be  remembered  that  it  is  clearly  an  advantage  to  the 
physician  not  only  to  provide  the  infant  with  a  good  imitation  of  human 
milk,  but  also  to  be  able  to  vary  the  proportion  of  the  constituents  to  suit 
the  idiosyncrasies  of  the  patient  as  well  as  the  abnormal  conditions  of 
digestion  produced  by  disease.  In  order  to  provide  these  advantages,  milk 
laboratories  have  been  established  in  various  cities  of  the  States,  and  other 
cities  will  doubtless  follow.  The  pioneer  work  in  this  direction  has  been 
done  by  Dr.  T.  M.  Rotch  of  Boston,  U.S.A.,  and  the  first  milk  laboratory 
was  established  there  under  his  direction.  There  must  necessarily  be  a 
farm  in  connection  with  the  laboratory,  where  healthy  milch  cows  are  kept 
under  the  most  strict  sanitary  conditions,  the  most  rigid  care  being  taken  to 
prevent  the  entrance  of  bacteria  into  the  milk,  and  to  insure  a  milk  of  good 
quality.  Then  by  means  of  a  i6  per  cent,  cream  obtained  by  the 
separator,  diluted  with  separated  milk  and  a  solution  of  milk  sugar,  any 
prescription  sent  to  the  laboratory  can  be  made  up  and  supplied  to  the 
patient.  It  is  certain,  however,  that  milk  laboratories  will  for  the  present 
at  least  be  out  of  the  reach  of  the  majority  of  practitioners,  and  the  expense 
will  stand  in  the  way  in  many  cases.  The  food  of  the  infant  will  for  long 
to  come  have  to  be  prepared  at  home.  Many  attempts  have  been  made  by 
physicians,  Biedert,  Meigs,  Frankland,  to  prepare  mixtures  of  cream  and 
milk  sugar,  which  should  be  good  copies  of  human  milk.  The  difficulty 
has  always  been  to  obtain  a  cream  of  definite  and  constant  strength.  The 
cream  of  the  shops  varies  much  in  strength,  and  moreover  is  often  by  nO' 
means  fresh,  and  frequently  contains  boric  acid  or  other  preservative. 


Fig.  9. 


Modified  Milk — HiiiiuDiiscd  Milk — CreaDi  Mixtures      49 

1  he  plan  we  have  followed  for  some  years  has  been  to  prepare  humanised 
milk  by  obtaining  a  weak  cream  by  the  gravity  method,  and  adding  to  it  a 
solution  of  sugar  of  milk.  The  details  are  as  follows  :  stand  30  oz.  of 
good  fresh  milk  of  average  quality,  as  soon  as  it  arrives  at  the  house,  in  a 
glass  bottle  such  as  is  supplied  with  Hawksley's  steriliser  (see  fig.  9).  A 
stopper  of  clean  non-absorbent  cotton  wool  is  placed  in  the  neck  of  the 
bottle  ;  it  is  allowed  to  stand  without  being  disturbed  for 
five  hours  in  an  ice  chest  or  in  as  cool  a  place  as  possible. 
By  the  end  of  this  time  a  certain  amount  of  cream  will 
have  risen  to  the  top.  Then  carefully,  and  without  dis- 
turbing the  bottle,  syphon  off  the  lower  half,  that  is, 
15  oz.,  and  replace  this  by  an  equal  quantity  of  a  7  per 
cent,  solution  of  sugar  of  milk  (i  oz.  of  sugar  of  milk  in 
1 5  oz.  of  water).  The  bottle  is  then  placed  in  the  steriliser 
and  the  mixture  kept  at  a  temperature  of  160°  F.  for  half 
an  hour.  It  is  then  cooled  as  quickly  as  possible  in  run- 
ning or  ice  water  and  kept  in  a  cool  place.  When  the 
infant  has  to  be  fed,  as  much  as  is  required  is  placed  in 
the  feeding  bottle  and  warmed  up  to  100°  F.  Such  a 
mixture  will  contain  about  3  to  3-5  fat,  i-8  proteid,  and 
6  milk  sugar. 

This  mixture  is  too  strong  for  a  delicate  or  very  young  infant,  and  a 
weaker  mixture  may  be  made  as  follows  :  let  the  milk  stand  as  before,  then 
syphon  off  20  oz.  and  replace  by  the  same  amount  of  solution  of  sugar  of 
milk  (I  oz.  in  20  oz.).  In  all  cases  it  is  as  well  to  render  the  mixture 
alkaline  by  the  addition  of  a  few  grains  of  bicarbonate  of  soda  or  a  few  drops 
of  a  saccharated  solution  of  lime.  We  must  bear  in  mind  that  the  ordinary 
household  milk  is  usually  richer  in  winter,  when  the  cows  are  stall-fed,  than 
in  spring,  when  they  are  out  to  pasture.  The  five  hours'  standing  may  be 
increased  or  shortened  according  to  the  richness  of  the  milk.  The  amount 
of  fat  in  the  mixture  can  be  readily  estimated  by  means  of  the  acid  centri- 
fuge machine  (see  Appendix). 

The  best  way  to  start  the  syphon  is  to  fill  it  with  water,  nip  the  end  of 
the  rubber  tube  so  as  to  prevent  the  water  from  running  out,  carefully  place 
the  short  leg  of  the  syphon  in  the  bottle  so  that  it  touches  the  bottom, 
release  the  end  of  the  rubber  tube,  and  the  milk  will  flow  out. 

Another  method  consists  in  allowing  the  milk  to  stand,  creaming  it 
with  a  spoon  and  making  a  mixture  of  cream,  fresh  milk,  and  sugar  water. 
If  the  creaming  operations  are  carried  out  with  care  a  number  of  modifica- 
tions can  be  made  (Holt,  Westcott).  A  cream  containing  12  percent,  of  fat 
is  the  most  convenient  for  use.  This  can  be  obtained  with  a  fair  amount  of 
accuracy  by  allowing  a  quart  of  milk  of  average  richness  to  stand  in  a  glass 
jar,  surrounded  by  iced  water,  for  six  hours. 

At  the  end  of  this  time  carefully  remove  by  skimming  the  cream  which 
has  arisen  (about  six  ounces).  By  diluting  this  12  per  cent,  cream  with 
different  quantities  of  sugar  water,  mixtures  of  varying  strength  will  be 
obtained,  the  fat  being  throughout  as  compared  with  the  proteids  in  a 
proportion  of  3  to  i. 


50  The  Hygiene  mid  Diet  of  Infants  and  Children 

Formula  obtaifzed  by  Diluting  12  per  cent.  Cream  {Holt) 


Cream 

Sugar  solution 

Fat 

Proteids 

Sugar 

Per  cent. 

Per  cent. 

Per  cent 

(i)  I  part 

5    parts  = 

2 

•6 

6 

(2)   I        „ 

4        „       = 

2-5 

•8 

6 

(3)  I      „ 

3       „      = 

J 

I 

6 

(4)  I      „ 

-71             — 

3-5 

1-2 

6 

(5)  I      „ 

2       „      = 

4 

1-3 

6 

In  (i)  and  (2)  the  sugar  solution  is  made  by  dissolving  i  oz.  in  16^  oz. 
of  water,  and  in  (3)  (4)  (5)  by  dissolving  i  oz.  in  14  oz.  of  water. 

The  following  table  shows  the  amount  of  12  per  cent,  cream,  whole 
milk,  and  sugar  of  milk  required  for  a  mixture  of  40  oz.  (Westcott)  : 


Cream 

Milk 

Milk  Sugar 

Fat 

Proteids 

Sugar 

oz. 

oz. 

oz. 

Per  cent. 

Per  cent. 

Per  cent. 

2-3 

13 

175    = 

2 

1-5 

6 

4-8 

IO-6 

2-5 

1-5 

6 

7-3 

8-1 

))        ~ 

3 

1-5 

6 

9-8 

5-6 

?!             ~ 

3-5 

1-5 

6 

12-3 

3-1 

))             ~ 

4 

1-5 

6 

Thus  if  a  mixture  was  required  to  contain  3  per  cent,  fat,  1*5  per  cent 
proteid,  6  per  cent,  sugar,  the  directions  would  be  given  thus,  in  round 
figures  : 

Cream  (12  per  cent.)        .     7  oz.         Lime  water    .         .         .2  oz. 

Whole  milk      .         .         .     8  oz.         Sugar  of  milk         .         .     if  oz. 

Add  water  to  make  40  oz. 

Whey. — Whey  is  an  extremely  useful  food  for  a  newly  born  or  weakly 
infant.  It  is  also  often  of  great  service  as  a  substitute  for  richer  foods  during 
a  period  of  indigestion.  It  may  be  often  usefully  employed  as  a  diluent 
for  cow's  milk.  It  is  best  prepared  b)'  warming  30  oz.  of  milk  in  a  glass 
bottle  (see  fig.  9)  or  saucepan  to  a  temperature  of  104°  F.,  adding  a  teaspoon- 
ful  or  two  of  Benger's  essence  of  rennet ;  allowing  to  stand  for  a  few  minutes 
till  coagulation  has  taken  place,  then  stirring  and  agitating  the  contents  of  the 
bottle,  so  as  to  break  up  the  curd  and  liberate  some  of  the  fat,  then  straining 
through  muslin  or  a  fine  sieve  ;  30  oz.  of  milk  will  yield  about  23  oz.  of  whey. 
Whey  so  prepared  contains  about — fat  1  -5  to  2  per  cent.,  proteids  -8  to  -g 
lactose  475,  salts  '6.  (F.  Baden  Benger.)  The  whey  should  be  sterilised, 
and  it  will  probably  require  straining  again,  as  a  slight  separation  of  proteid 
takes  place.  In  some  cases  of  weak  digestion  it  may  be  wise  to  dilute  the 
whey  with  barley  water.  On  the  other  hand,  if  it  is  found  that  whey  agrees 
with  an  infant  and  it  is  thriving,  milk  may  be  added  to  the  whey  after 
sterilisation,  and  some  milk  sugar  also  added.  A  weak  humanised  milk 
may  be   made  by  mixing   10  oz.  of  milk  with  20  oz.  of  whey,  and  adding 


IV/uy — Diluted  Milk — Barley    Water,  &€.  51 

i  oz.  of  milk  sugar.     To  make  a  stronger  humanised  milk  use  an  8  per  cent, 
cream  instead  of  ordinary  milk  for  the  above  mixture. 

Diluted  IVIilk.. — Undoubtedly  the  readiest  way  to  prepare  an  infant's  food 
is  to  dilute  milk  with  water  and  lime  water,  and  add  sugar.  That  food  so 
prepared  is  inferior  to  the  food  in  which  cream  forms  the  basis  is  evident, 
yet  it  cannot  be  denied  that  very  many  children  are  brought  up  on  diluted 
cow's  milk  and  appear  to  thrive  on  it.  Many  such  children  pass  much  curd 
in  their  stools  without  being  the  worse  for  it.  The  poorer  classes  cannot 
get  fresh  cream,  or  indeed  any  cream  at  all,  and  have  from  necessity  to 
prepare  their  infants'  food  from  milk.  As  we  should  naturally  suppose,  it  is 
the  newly  born  infants  who  are  most  intolerant  of  cow's  milk,  and  great  care 
is  required  in  adapting  the  strength  of  the  milk  to  the  infant's  condition.  It 
is  necessary  at  first  to  dilute  the  cow's  milk  with  two-thirds  sugar  water,'  one- 
twentieth  part  consisting  of  added  lime  water,  so  as  to  secure  that  the  food 
should  be  faintly  alkaline.  We  should,  however,  much  prefer  to  give  a  newly 
born  baby  whey  or  diluted  peptonised  milk  if  it  is  necessary  to  feed  it 
artificially.  After  the  first  three  or  four  weeks,  if  the  infant's  digestion 
appears  good,  half  milk  and  half  sugar  water  -  may  be  given  (one-twentieth 
part  being  lime  water).  From  three  months  of  age  to  six  months,  one- 
third  part  of  sugar  water  should  be  added. 

Barley  "Water,  Oatmeal  "Water,  &.c. — For  many  years  past  it  has  been 
the  practice  to  use  certain  thin  gelatinous  fluids,  such  as  barley  .water,  oat- 
meal water,  arrowroot  water,  or  fluids  containing  maltose  and  dextrin,  to 
dilute  milk  with  for  infant  feeding.  All  these  fluids,  except  perhaps  the  last 
named,  contain  small  quantities  of  starch.  Now  it  is  certain  that  the  powers 
of  young  infants  for  converting  starch  into  sugar  are  feeble,  and  if  these 
fluids  are  used  care  should  be  taken  in  their  preparation  to  avoid  any  cjuan- 
tity  of  starch  being  present.  The  saliva  of  infants  three  or  four  months  old 
has  undoubted  powers  of  starch  transformation,  and  apparently  the  pancreatic 
and  incestinal  juices  have  also,  so  that  by  the  time  this  age  is  reached  we 
have  nothing  to  fear  from  thin  starchy  fluids.  It  has  been  claimed  for  these 
gelatinous  fluids  that  when  used  to  dilute  milk  they  play  a  useful  part  in 
preventing  the  curd  from  running  together  into  lumps  during  the  time  that 
coagulation  is  taking  place.  It  is  certainly  difficult  to  demonstrate  this  in  a 
test  tube,  but  it  is  probable  that  any  colloidal  or  gelatinous  fluid  interferes 
with  the  rapid  diffusion  of  the  curdling  ferment  through  the  fluid,  and  conse- 
cjuently  the  curdling  takes  place  slowly,  and  there  is  m  consequence  less 
tendency  to  the  formation  of  lumps  of  curd.  Neither  starch  nor  maltose  is 
present  in  the  natural  food  of  infants,  yet  experience  teaches  that  the  addition 
of  a  thin  malted  food  or  barley  or  oatmeal  water  has  a  considerable  nutritive 
value,  and  we  entertain  no  doubt  on  this  point.  For  infants  below  six 
months  of  age,  we  dilute  milk  more  or  less  in  order  to  reduce  the  amount 
of  curd  present  ;  in  doing  so  we  render  the  food  poorer  in  hydrocarbons  than 
mother's  milk.  This  diluted  milk  is  rendered  more  nutritive  by  the  addition 
of  malted  starch,  and  this  is,  in  some  instances  at  least,  more  readily  assimi- 
lated than  milk  diluted  with  water  only. 

1  Dissolve  I  oz.  of  milk  sugar  in  20  oz.  of  water. 
^  Dissolve  I  oz.  of  milk  sugar  in  15  oz.  of  water. 


52  Tlie  Hygiene  and  Diet  of  Infants  and  CJiildren 

Peptonised  Milk. — The  predigestion  of  the  curd,  or  rather  the  caseino- 
gen  of  cow's  milk,  is  undoubtedly  a  useful  resort  in  the  artificial  feeding  of 
infants.  It  can  be  easily  demonstrated  that  milk  partially  peptonised  less 
readily  curdles  on  the  addition  of  rennet  or  acid,  and  that  the  curd  thrown 
down  is  softer  than  that  thrown  down  from  fresh  cow's  milk.  Clinical 
experience  also  testifies  to  its  value,  especially  in  infants  with  irritable 
stomachs  or  gastric  catarrh.  It  does  not,  however,  always  agree  with 
infants  ;  speaking  generally,  it  is  of  more  use  in  gastric  than  in  intestinal 
disturbances.  It  is  not  wise  to  continue  its  use  for  many  months  together  ; 
the  infant  should  gradually  become  used  to  milk  which  has  not  been 
predigested.  If  it  is  the  sole  food  for  many  months,  especially  after  the 
sixth  or  seventh  month  of  life,  scurvy  is  very  apt  to  arise.  The  best  way  to 
prepare  this  form  of  food  is  to  utihse  the  cream  mixture  already  referred 
to,  and  also  the  sterilising  apparatus.  A  reliable  peptonising  powder  con- 
taining pancreatine  and  soda  may  be  added  to  the  mixture  when  nicely 
warm  (iio°  F.),  and  the  temperature  raised  during  the  next  ten  minutes  or 
quarter  of  an  hour  to  i6o°  F.,  or  it  may  be  carried  to  the  boiling  point. 
Peptonising  for  ten  minutes  or  quarter  of  an  hour  does  not  much  alter  the 
flavour  of  the  milk,  but  this  time  is  not  long  enough  to  do  more  than  digest 
a  part  of  the  curd.  If  the  process  is  continued  for  half  an  hour  to  an  houi", 
the  curd  is  much  more  completely  digested,  but  a  bitter  taste  is  developed. 
In  quite  yeung  infants  this  bitter  milk  appears  to  agree  very  well  under  some 
conditions,  but  many  infants  will  not  take  it.  Peptonised  milk  food  may  be 
made  from  one  of  the  well-known  foods  prepared  by  Benger  &  Co.  or 
other  reliable  firms. 

Sterilisation. — Where  milk  can  be  obtained  absolutely  fresh  and  uncon- 
taminated  from  undoubtedly  healthy  cows,  and  is  consumed  at  once,  steri- 
lising processes  are  of  course  unnecessary,  but  only  infants  resident  in  the 
country,  where  cows  are  kept  on  the  premises,  can  have  these  advantages. 
Cow's  milk,  as  it  is  received  by  householders  in  towns,  is  usually  many  hours 
old  before  it  is  received,  and  it  may  be  kept,  or  at  least  some  portions  of 
it,  for  twenty-four  hours  longer  before  the  infant  takes  it.  During  this  time 
the  bacteria  which  it  has  received  by  means  of  various  contaminations 
multiply  enormously,  especially  in  hot  weather.  Milk  which  is  acid  and  , 
'just  on  the  turn '  is,  it  is  needless  to  say,  quite  unfit  for  infants'  food.  Many 
of  the  bacteria  found  in  stale  milk  are  probably  harmless,  or  at  any  rate  not 
actively  mischievous  ;  others  which  maybe  present,  especially  the  '  peptonis- 
ing bacteria,'  are  unquestionably  deleterious,  inasmuch  as  they  form  during 
their  growth  various  animal  poisons  of  the  ptomaine  type,  which  give  rise 
when  taken  to  acute  diarrhoea  or  gastro-enteritis. 

Various  pathogenic  bacteria  may  be  present  in  milk,  either  derived  from 
a  diseased  cow,  or  from  sewage  or  other  contamination  entering  the  milk. 
Tubercle  bacilli  may  be  derived  from  cows  suffering  from  tuberculosis  of  the 
udder,  and  there  can  be  no  doubt  that  diphtheria,  scarlet  fever,  typhoid  fever, 
and  foot  and  mouth  disease  may  be  spread  through  contaminated  milk. 
Fortunately  all  these  bacteria  are  destroyed  at  a  temperature  of  boiling 
water  ;  indeed,  there  is  good  evidence  that  they  cannot  withstand  a  tem- 
perature of  75°  C.  if  continued  for  half  an  hour.  Of  the  saprophytic  bacteria 
there  are  many  varieties.     There  are  the  lactic  acid  group,  and  with  these 


Sterilisation — Condensed  Milk  53 

are  the  butyric  acid  producers.  Others,  which  are  much  more  importantj 
are  those  which  do  not  act  on  the  lactose,  but  if  present  in  sufficient  numbers 
peptonise  the  proteids,  forming  peptones  and  albumoses.  Milk  containing 
the  latter,  if  it  is  at  all  stale,  given  to  mice  or  guinea  pigs  produces  diarrhoea, 
while  pure  cultures  quickly  produce  diarrhoea  and  death. 

Sterilising  for  household  purposes  rests  on  a  somewhat  different  footing 
from  sterilising  in  large  establishments  where  the  milk  has  to  keep  for  many 
months.  The  milk  sterilised  in  the  household  has  only  to  be  kept  for  twenty- 
four  hours  or  thereabouts,  and  therefore  so  high  or  continuous  a  temperature 
is  not  required.  The  success  of  the  sterilising  process  largely  depends  upon 
getting  the  milk  fresh  and  clean,  and  consequently  containing  few  bacteria 
and  no  spores.  It  is  impossible  in  a  household  to  sterilise  stale  milk. 
Stale  milk  is  certain  to  contain  many  spores,  and  the  spores  of  some  of  the 
saprophytic  bacteria  such  as  those  which  attack  casein  require  a  tempera- 
ture of  100-105°  C.  or  more  to  destroy  them.  If  the  milk  can  be  procured 
fresh  and  clean  and  is  intended  to  be  consumed  within  a  day  or  two,  a  tempera- 
ture of  70°  or  75"  C,  is  quite  high  enough  to  expose  the  milk  to.  This  tempera- 
ture does  not  affect  the  taste  or  coagulate  the  lactalbumen.  If  milk  has 
to  be  kept  a  longer  time  or  is  not  very  fresh,  it  is  better  to  expose  it  to  a 
temperature  of  100°  C.  for  half  an  hour.  Milk  which  is  long  heated  at  100°  C. 
or  especially  a  higher  temperature  suffers  certain  changes,  the  chief  of 
which  is  connected  with  the  coagulation  of  the  albumen  and  the  partial 
destruction  of  the  fat  emulsion.  In  such  milks  some  of  the  fat  floats  in  the 
form  of  large  globules  of  butter  on  the  top  of  the  milk  when  it  is  warmed.  A 
brown  colour  is  developed  on  account  of  the  partial  destruction  of  the  lactose. 
Milk  long  heated  suffers  coagulation  less  perfectly  than  raw  milk  ;  this  is 
due  to  the  precipitation  of  some  of  the  calcium  salts.  There  can  be  no 
doubt  that  the  formation  of  the  butter  oil  is  a  disadvantage  ;  how  far  the  less 
perfect  coagulation  of  the  curd  is  an  advantage  it  is  not  easy  to  say. 

Various  forms  of  apparatus  have  been  devised  for  sterilisation  in  the 
household,  the  best  known  being  on  the  Soxhiet  type.  This  form  can  be 
used  for  heating  to  100°  C.  or  to  the  lower  temperature  of  75°  C.  (167°  F.). 
Hawksley  has  also  devised  a  steriliser  with  a  thermometer,  which  is  con- 
venient and  reliable.  Aymard's  steriliser  is  also  convenient  for  the  purpose. 
Freeman's  is  much  used  in  America. 

Condensed  Milk. — Condensed  milk  has  long  been  a  favourite  substitute 
for  mother's  milk  among  the  lower  classes,  and  its  use  is  by  no  means  con- 
fined to  the  lower  orders,  though  it  has  had  but  few  defenders  among 
medical  men.  The  fact  that  some  brands  contain  a  large  proportion  of  added 
cane  sugar  has  condemned  it  in  the  eyes  of  most  medical  writers,  and  many 
serious  allegations  have  been  made  against  it.  It  has  been  accused  of  pro- 
ducing eczema,  diarrhoea,  constipation,  rickets,  scurvy,  and  it  has  been 
alleged  that  while  children  who  have  been  brought  up  on  it  are  fat  and 
plump,  they  readily  succumb  when  attacked  with  acute  disease.  On  the 
other  hand,  it  is  sterile  when  taken  from  a  freshly  opened  tin,  and  does  not 
readily  undergo  fermentative  changes  in  the  stomach.  It  will  often  be 
retained  when  so-called  fresh  milk  is  vomited  or  gives  rise  to  flatulence  and 
colic.  We  believe  it  may  often  be  substituted  for  fresh  milk  with  advantage 
as  a  temporary  resort,  care  being  taken  to   select  a   reliable  brand  which 


54  The  Hygiene  and  Diet  of  Infants  and  Children 

contains  a  full  percentage  of  fat.  The  best  varieties  are  those  which  have 
been  preserved  without  the  addition  of  cane  sugar,  and  to  which  cream  has 
been  added.  We  should  not  advise  condensed  or  any  form  of  preserved 
milk  for  months  together  on  account  of  the  risk  of  scurvy.  Care  should  be 
taken  when  a  tin  is  opened  to  make  sure  that  the  milk  is  in  good  condition, 
as  occasionally  a  tin  containing  partially  decomposed  milk  may  be  met 
with. 

In  using  condensed  milk  accurate  directions  must  be  given  as  to  the 
strength  to  be  employed  and  also  as  to  the  manner  of  measuring  it.  A 
graduated  measure  should  be  employed  and  the  milk  poured  into  it.  For  an 
infant  of  three  months  old  it  may  be  diluted  i  in  8  by  weight,  or  what  is  nearly 
equivalent  to  this,  i  in  lo  by  measure.  It  should  rarely  be  used  stronger 
than  this,  but  it  may  be  necessary  to  dilute  to  i  in  15  or  20  for  very  young 
infants,  and  in  special  cases. 

Diluted  to  I  in  8  by  weight,  we  shall  have  the  following  composition 
(Leeds)  : 


Sweetened 

Diluted 

condensed  milk 

I  in  8  by  weight 

Fat     . 

.       I2-IO 

1-51 

Lactose 

.       16-62 

2 -06 

Cane  sugar 

.      22-26 

2-78 

Proteids     . 

.       16-07 

2-01 

Ash    . 

2-6i 

•32 

Total  solids 

.   69-66 

8-68 

It  is  important  to  use  a  good  brand  of  condensed  milk,  inasmuch  as 
the  cheaper  forms  are  deficient  in  fat.  The  '  Milkmaid '  brand  contains 
nearly  1 2  per  cent,  of  fat,  while  some  other  brands  have  less  than  2  per  cent. 

Some  good  brands  of  condensed  milk  may  be  obtained  without  added 
sugar.  The  following  is  an  analysis  of  the  '  Viking '  brand  ;  it  will  be  seen 
that  it  corresponds  with  a  good  milk  which  has  been  concentrated  by  driving 
off  two-thirds  of  the  water.  A  measured  ounce  of  this  milk  weighs  480  grs., 
that  is  one-tenth  more  than  an  ounce  of  water.  It  can  be  diluted  for  use  i  in 
4  or  6  by  measure. 


Fat     . 
Lactose 
Proteids 
Ash    . 

Solids 


Unsweetened 
condensed  milk 


34-0 


Diluted  _ 
I  in  5  by  weight 

1-65 

2-2 

1-5 

-16 


5-51 


It  will  be  seen  by  examining  the  second  columns  that  each  of  these  foods 
is  deficient  in  fat,  while  the  latter  is  deficient  in  carbo-hydrates,  but  this  can 
be  remedied  by  adding  sugar.  It  is  well  to  bear  in  mind  that  in  all  concen- 
trated or  desiccated  milks  the  calcic  phosphates  are  thrown  down  in  a  more 
or  less  insoluble  form,  and  in  pi'eparing  the  food  in  the  ordinary  way  are 
only  in  part  redissolved. 

Dried  Milk  Foods. — The  difficulties  attendant  on  the  preparation  and 
storage  of  sterilised  milk  for  sale  have  brought  into  the  market  various 


Dried  Milk  I'oods  55 

preparations  of  desiccated  milk.  These  will  keep  good  in  any  climate,  and 
occupy  only  a  small  bulk  as  compared  with  liquid  preparations.  They  are 
unquestionably  convenient,  are  sterile,  and  their  proteids  are  more  readily 
digestible  than  the  proteids  of  much  that  passes  as  fresh  milk.  Messrs. 
Allen  &  Hanbury  prepare  two  forms  of  desiccated  milk  food.  The  following 
analysis  is  from  the  '  Lancet  :  ' 

A.  and  H.'s  No.  i  food  Diluted  i  in  8  by  weight 

Fat       ....  13-15  1-64 

Lactose  and  dextrin     .  65 -48  8"I9 

Proteids        .         .         .  14-25  1-78 

Salts     ....  475  -6 

In  using  this  food  accurate  directions  should  be  given  for  its  preparation. 
The  useful  tablespoon  should  not  be  used  as  a  measure,  but  a  dry  graduated 
measure  glass.  Six  measured  drachms  (220  grs.)  of  No.  i  food  weigh  half 
an  ounce,  water  is  to  be  added  to  make  up  4  oz.  in  all. 

The  composition  of  No.  2  food  is  very  similar,  but  with  a  small  quantity 
of  malt  extract  added.  No.  i  is  most  suitable  for  the  first  three  months  of 
life,  and  No.  2  for  the  next  three  months.  No.  3  food  consists  of  a  malted 
starch  food  and  requires  mixing  with  fresh  milk. 

The  chief  value  of  these  dried  milk  foods  consists  in  their  being  useful 
substitutes  for  fresh  milk,  when  the  latter  cannot  be  obtained,  or  when  the  infant 
suffers  from  frequent  vomiting,  colic,  or  diarrhoea.  They  do  not  readily 
ferment  in  the  stomach,  and  consequently  less  gas  is  formed,  as  compared 
with  some  forms  of  fresh  milk.  At  the  same  time  it  is  certain  that  they 
cannot  be  perfect  foods  inasmuch  as  they  are  deficient  in  fat  and  also  in 
lime  salts.  The  added  water  does  not  redissolve  the  whole  of  the  calcium 
salts  m  the  food.  If  continued  for  many  weeks  or  months,  specially  if  the  infant 
is  over  six  months  of  age,  both  scurvy  and  rickets  are  very  apt  to  ensue. 
Some  of  the  worst  cases  of  scurvy  which  we  have  seen  have  been  in  infants 
fed  solely  on  desiccated  milk  foods. 

Amount  or  Food  to  be  g-iven. — The  amount  of  food  to  be  given  to  an 
infant  must  necessarily  depend  not  only  on  its  age,  but  also  on  its  digestive 
powers  and  its  development.  It  is  evident  that  it  is  quite  as  important  to 
carefully  regulate  the  times  of  taking  food  and  the  amount  to  be  taken,  as  it 
is  to  decide  upon  the  nature  of  the  food.  It  must  of  course  be  borne  in 
mind  that  the  amounts  given  below  are  for  an  infant  of  average  weight  and 
digestive  powers.  Neither  age  nor  weight  should  be  taken  blindly  as  a  guide 
to  the  amount  of  food  an  infant  should  take.  For  the  first  two  or  three 
weeks  (weight  6  to  8  lb.),  give  i  to  2  ounces  of  food  every  two  hours  and  a 
half  in  the  daytime  ;  8  bottles  being  given,  and  12  to  15  ounces  of  food  being 
taken  in  the  twenty-four  hours. 

During  the  second  month  (weight  8  to  1 1  lb.),  3  to  4  ounces  of  food  every 
two  hours  and  a  half ;  8  bottles  being  given,  and  20  to  30  ounces  being  taken 
in  the  twenty-four  hours. 

During  the  third  and  fourth  months  (weight  11  to  14  lb.),  4  to  5  ounces 
of  food  every  three  hours  ;  7  bottles  being  given,  and  30  to  35  ounces  being 
taken  in  the  twenty-four  hours.  ». 

During  the  fifth  and  sixth  months  (weight  14  to   16  lb.),  6  to  7  ounces  of 


56  The  Hygiene  and  Diet  of  Infants  and  Children 

food  may  be  given  every  three  hours  ;  6  bottles  being  given,  and  35  to  40 
ounces  being  taken  in  the  twenty-four  hours. 

Feeding'  Bottles. — The  simplest  feeding  bottles  are  the  best.  It  is  wise 
to  avoid  all  those  provided  with  india-rubber  tubes,  corks,  and  those  that 
have  indented  letters  on  their  surfaces.  The  rubber  tubes  soon  crack  and 
become  rough  inside,  corks  absorb  some  of  the  food  and  quickly  become 
foul,  while  any  indentations  on  the  inner  surface  of  the  bottle  make  it 
difficult  to  scour  clean  with  a  brush.  The  best  class  of  bottles  are  those 
with  rather  wide  mouths  (see  fig.  10),  or  such  as  are  supplied  with  Soxhlet's 
or  Escherich's  milk  sterilisers,  and  are  perfectly  plain  and  fitted  with  large 
teats  that  can  be  turned  inside  out  for  the  purpose  of  cleansing.  The 
.,=^  small    teats    supphed  with  the  fancy  bottles   cannot  be 

readily  cleaned.  The  bottles  after  being  used  should  be 
thoroughly  cleaned  with  a  brush  kept  for  the  purpose, 
and  inverted  so  that  they  may  drain  and  no  dust  may 
be  allowed  to  get  into  them.  It  is  important  that  the 
food  should  not  be  given  too  hot ;  at  a  temperature  of 
98°  F.  it  is  quite  warm  enough. 

Diet  from  6  to  12  Months. — While  some  mothers 
are  strong  enough,  and  are  sufficiently  good  nurses,  to 
suckle  their  children  to  the  end  of  the  first  year,  there 
are  many  others  who  begin  to  flag  about  the  6th  or  7th 
month,  and  in  such  cases  it  is  desirable  to  supplement 
the  breast  by  means  of  some  milk  food.  There  is  no 
lack  of  artificial  or  patent  foods  from  which  to  choose. 
If  the  infant  is  entirely  dependent  upon  artificial  food, 
it  should  take  from  i^  to  2  pints  of  good  cow's  milk 
every  twenty-four  hours,  between  6  months  and  i  year. 
Whether  this  should  be  given  undiluted  must  depend 
upon  the  digestive  powers  of  the  infant,  which  may  be 
gauged  by  its  power  of  digesting  casein  as  determined 
by  an  inspection  of  its  stools  and  by  its  growth  and 
weight.  Some  form  of  starchy  food  may  be  added  with 
advantage,  for  now  the  digestive  powers  of  the  infant  are 
sufficiently  advanced  to  form  dextrine  and  maltose  out 
of  stai-ch,  thus  forming  a  valuable  and  easily  assimilated 
carbo-hydrate.  Care  must  be  taken  that  all  starchy  matters  are  thoroughly 
boiled,  so  that  the  starch  granules  become  gelatinised,  as  raw  starch  is  less 
easily  digested. 

Barley  jelly,  whole  meal  flour,  maize,  oatmeal,  all  answer  very  well 
if  thoroughly  cooked  and  made  sufficiently  thin  to  pass  through  the  teats  of 
ordinary  feeding  bottles. 

If  the  digestion  of  starch  is  not  proceeding  well  or  if  curd  is  being  passed 
in  the  stools,  malt  extract  or  '  Bynin'  may  be  added  to  the  food  after  it  has 
been  boiled,  and  allowed  to  become  just  cool  enough  to  taste  ;  it  is  then  set 
aside  for  a  few  minutes  before  giving  it.  Five  meals  in  the  twenty-four 
hours  will,  as  a  rule,  be  sufficient,  some  6  to  8  oz.  being  taken  at  each 
meal.  The  first  meal  may  be  taken  between  7  and  8  a.m.  ;  the  second 
between    10  and  11  A.M.;   the  third,   i    to  2  P.M.  ;    \h&  fotirth,  from  4  to 


Fig.  10. 


Feeding  Bottles  57 

5  P.M.  ;  and  ih&Jjfth,  the  last  thing  at  night.  There  is  no  harm  in  giving 
the  infant  a  well-toasted  crust  to  nibble,  but  thick  foods  should  not 
be  allowed,  and  beef  tea  and  eggs  are  certainly  unnecessary  and  best 
avoided. 

During  the  7th,  8th,  and  9th  months,  3^  oz.  to  3  oz.  will  be  an  average 
gain,  and  by  the  end  of  the  9th  month  20  lb.  weight  may  be  reached. 
During  the  last  three  months  2  oz.  to  It?  oz.  per  week  ;  and  the  weight  is 
usually  over  22  lb.  by  the  end  of  the  first  year. 

It  must  not,  however,  be  forgotten  that  infants  may  put  on  fat  which 
naturally  adds  to  their  weight  without  their  being  necessarily  strong  and 
healthy.  Care  must  be  taken  to  weigh  them  at  the  same  time  of  day,  so  that 
there  may  be  no  mistake. 

At  twelve  months  of  age,  if  the  child  be  strong  and  healthy,  the  bottle 
may  be  gradually  left  off,  and  food  of  a  more  solid  character  may  be  substi- 
tuted, but  milk  is  still  to  be  the  staple  food. 

Diet  from   Twelve   Months  to   Eig^hteen  Montbs  of  Agre 

First  meal^  7.30  A.M.     Fine  bread  sops  with  milk,  or  oatmeal  or  hominy 

porridge  made  with  milk. 
Second  meal,  11  A.M.     A  drink  of  milk. 
Third  meat,  1.30  P.M.     Bread  crumbs  and  gravy  or  a  lightly  boiled  egg  and 

bread  and  butter.     Sago  or  rice  pudding. 
Fourth  meal,  5.30  P.M.     Bread  and  milk. 
Fifth  meal.     Milk  to  drink. 

After  eighteen  months  of  age,  when  healthy  children  have  cut  their  first 
set  of  double  teeth,  small  quantities  of  fish,  fowl,  or  meat  may  be  allowed.  Of 
fish,  boiled  whiting,  sole,  or  cod,  carefully  freed  from  all  the  bones,  is  readily 
taken  by  most  children.  Boiled  fowl  is  better  than  butcher's  meat  in  early 
childhood.  Of  the  latter,  underdone  mutton  chops,  torn  into  shreds  and 
mixed  with  bread  crumbs  or  well-mashed  potatoes,  are  the  best  and  most 
digestible  kind  of  butcher's  meat.  Rice,  sago,  and  tapioca  puddings,  stewed 
apples,  and  preserves  of  various  fruits,  may  be  allowed.  Children  unfortu- 
nately are  often  strangely  fastidious  in  their  tastes,  and  will  frequently  take 
a  dislike  to  many  forms  of  the  most  digestible  foods.  It  is  always  well  to 
introduce  as  much  variety  as  possible  into  their  diet. 

For  older  children  hominy  porridge  with  treacle  for  breakfast,  to  be 
followed  by  small  quantities  of  bacon  or  tgg,  with  cocoa  or  weak  tea,  are 
as  a  rule  well  digested  and  are  beneficial,  provided  that  the  porridge  or 
bread  and  milk  forms  the  piece  de  resistance  of  the  repast.  Soups  made 
in  various  ways  from  meat  and  vegetables  form  an  exceedingly  wholesome 
and  digestible  meal.  Pastry,  as  a  rule,  is  bad  ;  boiled  rice  with  raisins  and 
stewed  fruit  of  various  kinds  are  much  to  be  preferred. 

When  the  child  is  old  enough  to  sit  up  to  table  at  dinner  and  take  meat 
cut  from  a  joint,  the  greatest  care  should  be  taken  to  see  that  the  meat  is 
carefully  cut  up  into  small  pieces  before  it  is  put  into  the  mouth,  and  is 
thoroughly  masticated  before  swallowing.  So  important  is  this,  that  if  there 
is  any  doubt  as  to  the  cutting  up  by  the  nurse,  it  will  be  well  to  insist  that  all 
the  meat  should  first  be  put  through  a  mincing  machine;  the  gravy  can 


58  The  Hygiene  and  Diet  of  Infants  and  Children 

be  afterwards  added  to  it.  Masses  of  half-masticated  meat  will  not  be 
digested  if  bolted  in  the  usual  way,  and  will  be  passed  almost  unchanged  in 
the  fseces  ;  and  if  the  food  is  thus  bolted,  it  is  less  satisfying,  and  leads  to 
more  than  is  required  by  the  system  being  consumed.  A  stand  must  always 
be  made  against  the  common  practice  of  giving  children  biscuits  or  ginger- 
bread at  almost  all  hours  of  the  day.  The  stomach  requires  rest  like  every 
other  organ  in  the  body,  and  is  certain  to  become  deranged  if  sweet  things 
are  being  taken  at  all  times. 

The  Care  of  Immature  and  "Weakly  Infants. — Infants  born  before  the 
full  time  of  forty  weeks  require  special  care  in  nursing  and  feeding,  and  this 
is  true  also  of  delicate  infants  born  at  full  time.  Infants  born  before  the 
thirtieth  week  and  weighing  under  2 ,  lb.  only  exceptionally  hve  more  than 
a  few  hours.  There  are,  however,  instances  on  record  of  infants  weighing 
under  2  lb.  at  birth  being  successfully  reared.  In  one  case  under  the  care 
of  Dr.  A.  Mumford  which  he  brought  under  our  notice  the  infant  weighed 
I  lb.  14  oz.  at  birth,  it  survived,  and  has  since  done  well.  Villeman  and 
Charpentier  and  others  have  recorded  somewhat  similar  cases.  Those  born 
at  the  thirtieth  or  thirty-first  week  and  weighing  2f  to  3  lb.  have  a  better 
chance  of  being  reared,  though  the  mortality  among  such  is  very  high. 
Those  born  at  the  thirty-sixth  week  and  weighing  4  to  4^  lb.,  or  at  the 
thirty-eighth  week  weighing  4^  to  5^  lb.,  have  a  good  chance  of  surviving, 
but  require  exceptional  care. 

For  the  most  part  premature  infants  have  but  little  subcutaneous  fat, 
and  feeble  powers  of  maintaining  their  temperature  ;  they  quickly  lose  heat 
and  readily  succumb  if  exposed  to  cold.  They  are  usually  of  a  dull-red 
colour  from  the  asphyxiated  condition  of  blood,  their  skin  hangs  in  loose  folds, 
their  movements  are  sluggish,  and  the  cry  is  feeble  in  consequence  of  the 
partial  expansion  of  their  lungs.  The  muscles  are  limp  and  toneless,  the 
respiratory  and  sucking  movements  wanting  vigour  as  compared  with  an 
infant  born  at  term.  No  washing  operations  must  be  attempted,  but  the 
infant  as  soon  as  it  is  separated  from  the  placenta  must  be  completely 
enveloped  in  warm  dry  absorbent  cotton  wool.  Separate  pieces  may  be 
made  to  envelop  the  limbs,  and  another  piece  in  contact  with  the  buttocks 
to  absorb  the  urine  and  faeces.  It  is  wrapped  in  blankets  or  woollen  wraps, 
placed  in  a  padded  basket  or  box,  and  kept  warm  with  hot-water  bottles. 
The  cotton  wool  diaper  can  be  removed  when  soiled,  and  the  rest  of  the 
cotton  wool  wrapper  may  be  renewed  daily  if  the  condition  of  the  infant 
admits  of  the  necessary  handling  and  exposure.  The  apartment  must  be 
kept  at  a  temperature  of  70°  F.  at  least  ;  much  higher  than  this  will  render 
it  very  uncomfortable  for  the  mother  and  attendants.  It  is  well  to  have  a 
cylinder  of  oxygen  in  the  apartment  to  use  for  the  infant  in  case  of 
necessity. 

The  feeding  of  premature  infants  is  likely  to  be  a  matter  of  some  diffi- 
culty ;  the  infant  may  be  too  feeble  to  suck,  and  very  likely  no  milk  may 
make  its  appearance  in  the  mother's  breasts.  The  breast  milk  in  these  cases 
is  likely  to  be  more  rich  in  proteids  than  ordinary  colostric  milk,  and  conse- 
quently may  disagree,  giving  rise  to  sickness  and  diarrhoea.  It  will  probably 
be  the  best  plan  to  draw  off  ihe  mother's  milk  at  intervals,  dilute  with 
warm  water,  and  give  it  to  the  infant  with  a  pipette  with  an  india-rubber  ball 


Ca7'e  of  Immature  and   Weakly  Infants  59 

attached.  Failing  the  mother's  breast,  steriHsed  whey  may  be  given  (i,  p.  50), 
or,  in  case  of  a  very  weakly  infant,  the  whey  must  be  diluted  with  an  equal 
quantity  of  water.  Two  to  four  drachms  may  be  given  hourly.  If  there  is 
much  vomiting,  or  if  the  infant  is  not  taking  its  food  well,  the  food  should  be 
introduced  direct  into  its  stomach  by  means  of  a  rubber  catheter.  (See 
Gav.\ge,  Appendix.) 

The  introduction  of  incubators  or  Brooders  has  undoubtedly  been  the 
means  of  saving  the  lives  of  premature  infants,  especially  in  maternity 
hospitals,  where  the  infant  can  be  placed  at  once  after  birth  in  the  apparatus. 
An  incubator  usually  consists  of  a  small  chamber,  which  can  be  kept  at  a 
temperature  of  90°  F.  if  need  be,  and  is  well  ventilated.  Various  forms  have 
been  designed  for  the  purpose  ;  the  one  most  used  in  this  country  is 
Hearson's,'  the  Couveuse  Lion  -'  being  largely  used  on  the  Continent.  It  is 
needless  to  say  that  the  management  of  a  baby-incubator  requires  the 
attendance  ot  intelligent  and  experienced  nurses. 

'  235  Regent  Street,  London,  W. 
-  26  Boulevard  Poissonni^re,  Paris. 


6o  Diseases  of  the  Digestive  System 


CHAPTER    IV 

DISEASES   OF   THE   DIGESTIVE   SYSTEM 

Examination  of  the  Mouth. — An  inspection  of  the  cavity  of  the  mouth 
and  fauces  in  infants  and  children  is  of  great  importance,  and  mistakes  in 
diagnosis  are  exceedingly  likely  to  be  made  if  it  is  neglected.  In  newly  born 
infants  the  mucous  membrane  of  the  mouth  is  comparatively  dry,  and  con- 
tinues so  for  the  first  two  or  three  months  of  life  ;  the  secretion  of  saliva 
becomes  gradually  freer  as  the  glands  develop,  and  the  infant  begins  to 
dribble,  for  it  is  some  time  before  it  learns  to  swallow  its  saliva  and  to  keep 
its  mouth  shut.  The  lining  of  the  infant's  mouth  is  at  first  of  a  dull  red 
colour,  and  flocculi  of  milk  are  often  to  be  seen  adhering  to  it,  as  the  move- 
ments of  the  tongue  and  lips  are  imperfect,  and  there  is  but  little  secretion 
of  fluid  to  cleanse  the  mucous  membrane.  All  through  infancy  and  early 
childhood  the  mucous  membrane  is  exceedingly  apt  to  become  the  seat  of 
various  lesions.  The  membrane  is  necessarily  delicate,  the  epithelium  is  easily 
injured,  and  affords  a  favourable  ground  for  the  cultivation  of  cryptogam ic 
growths  and  various  micro-organisms  ;  hence  the  frequency  with  which  we 
find  parasitic  stomatitis  and  various  superficial  ulcerations  and  aphthous 
patches. 

Inspection  of  the  mouth  of  the  newly  born  may  reveal  various  abnorma- 
lities, some  of  minor  importance,  such  as  the  small  millet-seed  nodules 
situated  in  the  middle  of  the  roof  of  the  mouth,  a  shortened  frsenum  linguae, 
or  the  presence  of  small  clear  swellings  (ranula)  beneath  the  tongue.  Among 
the  important  abnormalities  may  be  mentioned  cleft  palate,  or  an  abnormally 
high  arched  roof. 

All  through  early  life  there  is  a  tendency  to  hypertrophy  of  the  lymphatic 
tissues  in  the  naso-pharynx  and  fauces.  It  must  be  borne  in  mind  that  the 
passage  through  the  naso-pharynx  in  infants  is  exceedingly  narrow,  and  the 
presence  of  adenoid  excrescences  or  enlarged  pharyngeal  tonsil,  which  may 
perhaps  be  congenital,  may  seriously  interfere  with  the  infant's  respira- 
tion, and  in  some  instances  seems  to  excite  '  choking  fits,'  or  spasm  of  the 
glottis. 

Dentition. — The  influence  of  dentition  upon  the  health  of  the  infant  de- 
pends very  much  upon  the  child's  constitution.  A  strong  and  vigorous  infant 
which  has  been  brought  up  at  the  breast  will  cut  its  teeth  one  after  another 
without  trouble,  and  but  for  the  appearance  of  the  teeth  through  the  gums 
the  friends  will  not  be  aware  that  dentition  is  in  progress.  On  the  other 
hand,  if  the  infant  is  rickety,  weakly,  or  the  inheritor  of  neurasthenic  tenden- 
cies, the  period  of  dentition  will  be  a  period  of  danger,  and  the  irritation 


Dentition  6i 

caused  by  the  pressure  of  the  tooth  expanding  its  sockets  and  cutting  through 
the  gum  is  very  hable  to  give  rise  to  various  forms  of  disease,  the  process  of 
dentition  acting  rather  as  the  exciting  than  the  predisposing  cause.  The 
first  dentition  begins  during  the  middle  of  the  first  year,  and  ends  usually  by 
the  appearance  of  the  posterior  molars  in  the  middle  of  the  third  year.  In 
some,  v.'ithout  any  known  cause,  the  first  teeth  make  their  appearance  before 
this  time  ;  indeed,  it  is  not  infrequent  for  infants  to  be  born  with  a  tooth 
already  cut  :  such  teeth,  however,  are  imperfectly  developed,  and  consist 
merely  of  a  thin  shell  of  enamel.  Some  by  no  means  strong  children  cut 
their  teeth  early.  In  rickets  dentition  is  delayed  ;  in  those  cases  in  which 
rickets  makes  its  appearance  prior  to  the  sixth  month,  dentition  may  not 
commence  during  the  first  year,  the  infant  being  toothless  at  a  year  old.  In 
other  cases  the  infant  only  becomes  rickety  towards  the  end  of  the  first  year, 
when  the  incisors  are  perhaps  through  the  gum,  and  then  there  follows  a 
long  delay. 

By  the  fifth  or  sixth  month  saliva  is  formed  in  large  quantities,  so  that  it 
is  frequently  dribbling  from  the  mouth,  and  the  infant  is  constantly  putting 
its  finger  into  its  mouth,  as  if  there  were  some  sort  of  irritation  going  on 
there.  A  month  or  so  later  the  gums  may  become  tender,  the  whole  mucous 
membrane  congested,  aphthae  appear  on  the  tongue,  inside  the  lips,  or  on  the 
hard  palate,  and  the  infant  is  feverish  and  cross  to  a  degree.  Perhaps  now 
the  edge  of  a  tooth,  usually  one  of  the  lower  middle  incisors,  will  be  felt 
through  the  gum.  Some  days  or  even  weeks  will  perhaps  elapse  before  the 
edge  of  the  tooth  is  actually  cut.  It  is  a  singular  but  by  no  means  unusual 
circumstance  for  a  tooth  to  advance  so  as  almost  to  stretch  the  mucous 
membrane  of  the  mouth,  and  then  become  stationary  for  some  time. 

Now  while  it  is  the  almost  daily  experience  of  the  practitioner  that  the 
process  of  cutting  the  first  teeth  gives  rise  to  discomfort,  he  knows  also  that 
mothers  and  nurses  are  ever  ready  to  attribute  every  childish  illness  to  the 
teeth.  Many  infantile  ailments  are  mysterious  in  their  origin,  especially 
attacks  of  feverishness,  and  in  children  under  two  years  old  there  is  always 
a  tooth  nearly  cut,  or  has  just  been  cut,  or  is  about  to  be  cut,  to  supply  the 
explanation.  It  is  this  popular  tendency  to  attribute  every  childish  ailment 
to  the  teeth,  which  explains  the  large  sale  of  'teething  powders.'  The 
danger  is  that  important  errors  in  diet,  a  patch  of  pneumonia,  or  meningitis 
may  be  overlooked  if  the  teeth  are  allowed  to  explain  everything.  While  it 
is  unwise  to  shut  our  eyes  to  the  disturbance  and  discomfort  produced  by  a 
Stretched  and  swollen  gum,  care  is  needed  to  avoid  using  the  explanation  of 
'  tooth  cutting '  to  cover  ignorance  or  merely  to  satisfy  the  clamour  of  an 
.anxious  mother  for  a  definite  opinion  as  regards  her  child's  illness.  It  is  a 
good  rule  always  to  seek  for  an  explanation  elsewhere  than  in  the  teeth,  if 
there  is  no  local  lesion  in  the  gum,  such  as  swelling,  tenderness,  or  some 
evidence  of  inflammation. 

Feverishnass. — When  the  gum  is  swollen  and  tender  prior  to  the  cutting 
of  a  tooth,  the  infant  is  apt  to  be  irritable,  having  fits  of  crying  without  any 
apparent  cause,  which  nothing  will  pacify  ;  at  first  gently  rubbing  the  gum 
will  give  ease,  but  at  a  later  stage  this  only  aggravates  the  trouble  from  the 
acutely  painful  state  of  the  gum.  The  fever  is  intermittent,  the  child  being 
hot  and  feverish  for  the  most  part  at  night  and  unable  to  sleep,  while  towards 


62  Diseases  of  the  Digestive  System 

morning  it  cools  down  and  dozes  for  a  few  hours  ;  the  temperature  may 
reach  102°  or  103°,  rarely  more.  Such  attacks  may  often  pass  away  without 
the  tooth  being  cut,  or  may  continue  for  some  time  after  the  edge  of  the 
tooth  has  appeared,  and  before  the  rest  of  the  tooth  has  made  its  way 
through. 

Stomatitis. — The  mucous  membrane  of  the  mouth,  more  especially  that 
part  of  the  gum  where  the  tooth  is  about  to  appear,  the  tongue,  hard  palate, 
and  inside  of  the  cheeks,  may  be  the  seat  of  small  superficial  ulcers  or  small 
spots  denuded  of  epithelium,  their  surface  being  of  a  grey  or  yellowish 
colour,  and  their  edges  surrounded  by  a  zone  of  erythematous  redness. 
These  spots  are  evidently  sore,  and  may  be  the  cause  of  the  infant  refusing 
the  breast,  and  crying  whenever  liquids  containing  salines,  such  as  beef  tea, 
are  taken. 

Enlarged  Glands. — Occasionally  it  happens  in  children  predisposed  to 
glandular  enlargement  that  the  irritation  caused  by  these  aphthous  patches 
gives  rise  to  a  swelling  of  the  glands,  either  the  submaxillary  when  the  lower 
jaw  is  affected,  orthe  parotid  or  upper  cervical  lymphatic  glands,  which  receive 
the  lymph  from  the  upper  jaw.  These  swellings  may  quickly  subside,  or 
end  in  either  acute  or  chronic  suppuration.  In  the  latter  case  successive 
teeth  being  cut  keep  up  the  source  of  irritation. 

Diarrhoea  — During  the  hot  months  of  late  summer  and  autumn,  the 
irritation  of  teething  may  be  the  exciting  cause  of  intestinal  catarrh  and 
diarrhoea.  In  infants  a  transference  of  a  lesion  from  one  part  of  the  body, 
more  especially  from  one  mucous  membrane,  to  another,  is  exceedingly 
common  ;  this  diarrhoea  is  especially  common  in  artificially  fed  infants.  No 
diarrhoea  should  be  attributed  to  tooth  cutting,  unless  there  is  some  local 
lesion  in  the  gums  or  mouth. 

Bronciiitis. — During  dentition,  especially  when  the  incisors  are  being  cut, 
infants  seem  very  prone  to  catarrh  of  the  bronchial  tubes,  which  may  be 
complicated  by  catarrhal  pneumonia. 

-  Eczema  and  Lichen. — It  constantly  happens  that  infants  who  suffer,  or 
are  liable  to  suffer,  from  eczema  are  much  worse  while  a  tooth  is  pressing 
through  the  gum.  The  eczema  very  frequently  gets  well  in  the  intervals, 
the  face  and  body  being  free,  until  a  tooth  comes  near  the  surface,  and 
there  is  a  return  of  the  eczema,  the  face  and  forehead  flush  up  and  papules 
appear  which  begin  to  ooze  and  crust.  Lichen  in  the  form  of  strophulus  or 
urticaria  is  also  common. 

Convulsions. — It  may  be  taken  for  granted  that  no  healthy  infants  suffer 
from  convulsions  ;  those  who  do  are  either  rickety  or  the  children  of  neurotic 
parents,  and  inherit  a  tendency  to  nerve  disturbance.  Spasmodic  affections 
of  various  groups  of  muscles  occasionally  take  place. 

Treatment. — Much  controversy  has  arisen  from  time  to  time  with  regard 
to  the  use  of  the  gum  lancet,  and  the  propriety  of  employing  it  in  assisting 
dentition,  many  practitioners  being  in  the  frequent  habit  of  using  it,  while 
others  have  not  employed  it  for  years.  If  the  mucous  membrane  over  the 
tooth  is  red,  swollen,  and  tender,  and  the  edge  of  the  tooth  can  be  felt,  much 
pain  and  discomfort  will  be  spared  the  infant  by  its  use,  presuming,  of 
course,  it  is  not  a  '  bleeder,'  nor  comes  of  a  family  in  which  there  is  a  history 
of  heemophilia.     The  rehef  afforded  is  due  in  all  probability  to  the  local  loss 


Dentition  63 

of  blood;  as  well  as  to  the  relief  of  tension  in  the  gum.  That  it  has  been 
done  often  unnecessarily,  and  that  many  troubles  are  attributed  to  dentition 
that  have  no  connection  with  it,  is  no  argument  against  the  use  of  the  lancet 
in  proper  cases.  The  evidence  is  too  strong  to  be  lightly  explained  away, 
that  fits  of  crying,  feverishness,  or  even  convulsions  may  be  quickly  relieved 
by  freely  lancing  a  swollen  and  tender  gum.  It,  perhaps,  need  not  be  said 
that  it  is  useless  to  lance  the  gum  unless  there  is  evidence  that  the  cutting' 
edge  of  the  tooth  is  near  the  surface,  or  disappointment  will  certainly  follow. 
In  one  case  coming  under  our  notice,  in  which  an  upper  incisor  was  lanced 
in  a  rickety  child,  the  tooth  was  not  cut  till  exactly  a  year  after  the  operation. 
The  feverishness  and  tenderness  in  the  mouth  and  sleeplessness  may  be 
generally  relieved  by  mercurial  purges,  bromides,  or  simple  salines  (F.  i 
and  2).  As  much  as  five  grains  of  bromide  may  be  given  if  the  infant  is 
very  restless,  or  two  or  three  grains  of  chloral  hydrate,  or  a  mixture  containing 
two  and  a  half  grains  of  each  in  a  teaspoonful  of  syrup.  Painting  a  tender 
and  swollen  gum  with  a  saturated  solution  of  bromide  of  sodium  in  glycerine 
and  water  will  often  relieve  pain.  If  the  gums  remain  spongy,  or  there  is 
aphthous  stomatitis,  borax  with  tinct.  myrrh  may  be  used  (F.  3). 

The  temporary  teeth  differ  in  size  and  hardness  in  different  children  ; 
in  weakly  rickety  children  they  are  not  only  late  in  appearing,  but  when  they 
do  appear  are  dwarfed  and  consist  of  mere  shells,  quickly  becoming  black 
and  carious,  or  loose  and  falling  out  of  their  sockets.  In  other  children  the 
enamel  appears  deficient,  and  caries  occurs  early.  Great  care  should  always 
be  exercised  in  the  preservation  of  the  first  set  of  teeth.  A  soft  tooth  brush 
should  be  used  every  night,  and  the  mouth  thoroughly  cleansed  with  warm 
water,  in  order  to  dislodge  the  fragments  of  food  which  have  collected 
between  the  teetlf.  If  the  teeth  show  signs  of  caries,  it  is  a  good  plan  to 
use  the  tooth  brush  after  every  meal,  mixing  a  few  drops  of  an  alkaline 
mixture  with  the  water  (sp.  ammon.  aromat.  5J,  sp.  vini  rect.  ^iij)-  Whenever 
it  is  possible,  carious  temporary  molars  should  be  properly  filled. 

The  second  dentition  is  not  accompanied  by  the  same  troubles  as  the 
first,  or  at  any  rate  to  the  same  degree.  The  first  molars  and  incisors  usually 
make  their  appearance  unobserved,  and  rarely  occasion  any  inconvenience. 
The  second  molars  may  give  more  trouble.  It  sometimes  happens  that  the 
gums  get  into  an  unhealthy  state,  being  spongy  and  bleeding  readily,  while 
the  teeth  become  loose  and  give  pain  during  mastication.  It  is  during  this 
period  that  ulcerative  stomatitis  may  be  present.  Gumboils  may  be  another 
source  of  trouble.  If  it  is  of  importance  to  attend  to  the  cleansing  of  the 
mouth  during  early  childhood,  it  is  of  still  greater  importance  to  do  so  when 
the  permanent  teeth  are  appearing,  and  no  effort  should  be  spared  to  prevent 
their  premature  decay. 

The  structure  of  the  permanent  teeth  is  no  doubt  influenced  by  the 
state  of  the  health  during  infancy.  We  have  already  referred  to  the  fact 
(p.  14),  that  illness  taking  place  during  the  first  year  of  life  may  affect  the 
permanent  set  of  incisors  and  canines,  while  the  bicuspids  and  first  molars 
probably  and  last  two  molars  certainly  escape.  Mr.  Hutchinson  long  ago 
pointed  out  that  congenital  syphilis  often  gives  rise  to  a  peculiar  formation 
of  the  incisors  of  the  permanent  set.  The  '  test  teeth  '  for  syphilis  are  the 
upper  central  incisors  ;  the  effect  of  this  disease  occurring  during  infancy  is 


64  Diseases  of  the  Digestive  System 

to  arrest  their  development,  causing  dwarfing  and  also  a  central  notch  at 
the  cutting  edge,  or  perhaps  a  '  screw-driver  '  form  of  tooth  ;  the  other 
incisors  may  share  in  this  want  of  development,  but  only  in  a  secondary 
degree.  Mr.  Hutchinson  has  also  pointed  out  that  stomatitis  occurring 
during  infancy  gives  rise  to  a  pitting  or  erosion  of  the  enamel.  The  '  test 
tooth  '  for  infantile  stomatitis  being  the  first  molar,  the  incisors  also  may  be 
affected,  and  they  may  be  grooved  by  a  '  transverse  furi'ow  crossing  all  the 
teeth  at  the  same  level.'  In  some  cases  the  pitting  of  the  upper  surface  of 
the  molar  produces  well-marked  rugosities  {erosion  en  mamelon).  Other 
deficiencies  of  the  enamel  of  more  or  less  extent  have  been  described  by 
Ftench  authors.  Mr.  Hutchinson  believes  that  the  stomatitis  giving  rise  to 
this  condition  is  often  mercurial  in  its  origin,  mercury  having  been  given  in 
the  form  of  'teething  powders'  or  in  other  ways.  Mr.  Moon  used  to  speak 
of  a  '  mercurio-syphilitic '  tooth  in  which  there  was  a  want  of  enamel  over 
a  semilunar  space  near  the  cutting  edge,  and  in  consequence  a  breaking 
down  of  the  enamel  over  this  area.  M.  Magitot  attributes  erosion  of  the 
teeth  to  the  effects  of  infantile  convulsions,  but  it  is  probable  the  convulsions 
are  coincident  only. 

It  is  by  no  means  always  easy  to  explain  why  some  children  have  good 
teeth  with  perfect  enamel,  while  in  others  the  enamel  is  deficient  and  the 
teeth  quickly  become  carious.  There  cannot  be  any  doubt,  however,  that  a 
strong  and  vigorous  infancy  and  early  childhood  with  a  good  digestion  and 
careful  feeding  must  favourably  influence  the  development  of  the  teeth  ; 
while  infants  who  suffer  from  dyspepsia  and  are  badly  fed  will  suffer  later 
on  from  bad  teeth.     No  doubt  apparent  exceptions  may  occur. 

Diseases  of  the  IMCouth 

Catarrlial  Stomatitis. — Catarrhal  inflammation  of  the  mouth  may  be 
primary,  but  it  is  more  often  secondary,  accompanying  dentition,  dyspepsia, 
pneumonia,  and  other  diseases.  Stomatitis  is  especially  apt  to  make  its  ap- 
pearance during  the  first  year  of  life,  though  it  is  common  during  the  whole 
of  childhood.  Infants  who  are  thus  suffering,  having  begun  to  take  the  breast, 
suddenly  let  it  go  and  cry,  and  are  apt  to  stuff  their  fingers  in  their  mouths  ; 
they  are  feverish  and  irritable,  the  saliva  is  increased  in  quantity,  and  the 
mouth  feels  hot  if  the  finger  be  inserted  ;  the  salivary  glands,  especially  the 
sublingual,  are  swollen  and  tender.  On  examination  of  the  oral  cavity, 
patches  of  intense  redness  are  to  be  seen  on  the  mucous  membrane  inside 
the  cheek,  on  the  gums,  or  hard  palate,  the  tongue  is  generally  bright  red 
and  clean,  or  the  surface  is  covered  with  a  thick  creamy  fur,  the  edges  and  tip 
being  clean  and  red.  This  form  of  stomatitis  is  often  called  stomatitis 
erytbemiatosa.  Very  frequently  at  the  seat  of  these  erythematous  patches, 
an  exudation  of  yellowish  or  greyish  secretion  takes  place,  or  there  is  a 
breach  of  surface  where  the  epithelium  is  abraded,  and  small  shallow 
ulcers  are  formed.  These  yellowish  patches  or  ulcers  are  surrounded  by 
a  zone  of  redness.  Such  patches  are  usually  termed  Aphthae,  and  when 
present  the  term  '  aphthous  stomatitis  '  is  often  applied.  Older  children  are 
subject  to  these  attacks,  and  it  is  often  seen  to  affect  a  whole  household  at 
the  same  time,  the  adults  by  no  means  always  escaping.     It  is  uncertain  if 


Catarrhal  Stomatitis  65 

it  is  contagious,  but  it  is  certainly  epidemic  ;  it  is  sometimes  associated 
with  tonsillitis.  There  may  be  feverishness,  the  temperature  rising  to  103°, 
accompanied  by  the  appearance  of  vesicles  on  the  mucous  membrane  of  the 
lips,  tongue,  and  soft  palate  ;  the  vesicles  soon  disappear,  being  followed  by 
patches  of  yellow  exudation,  or  a  shallow  ulcer  may  remain.  The  spots 
remain  sore  for  several  days.  The  term  of  Herpetic  Stomatitis  is 
sometinies  applied  to  this  form.  Similar  attacks  have  been  described  as 
occurring  both  in  infants  and  children  from  drinking  the  unboiled  milk  of 
cows  suffering  from  '  foot  and  mouth '  disease  ;  and  in  any  case  where  these 
affections  occur  in  a  widespread  epidemic  it  is  well  to  make  careful  in- 
quiry into  this  as  a  possible  cause.  There  are  probably  several  distinct 
cliseases  resulting  from  specific  micro-organisms  included  under  the  term 
'  aphthous  stomatitis.'  Fraenkel  has  found  pus  cocci,  such  as  Staph,  pyog. 
cit7'eus  and  alhits,  as  well  as  'gas-forming  bacilli,'  in  stomatitis.  During 
attacks  of  tonsillitis,  scarlet  fever,  measles,  &c.,  aphthse  often  make  their 
appearence  on  the  tongue  and  inside  the  lips,  while  the  corners  of  the  mouth 
become  excoriated. 

Sometimes  patches  of  greyish-white  or  yellowish  membrane  form  on  the 
edges  or  sides  of  the  tongue  ;  this  form  has  been  called  IVXembranous 
Stomatitis.  It  has  nothing  to  do  with  diphtheria,  but  streptococci  have 
been  found  in  the  fibrinous  exudation. 

In  infants  aphthous  patches,  two  in  number,  situated  on  the  hard  palate, 
one  on  each  side  of  the  median  raphe,  near  the  junction  of  the  hard  and  soft 
palate,  are  often  seen  ;  these  are  round  surperficial  ulcers  \-\  in.  in  diameter, 
their  base  being  of  a  yellowish  colour  and  surrounded  by  erythema.  They 
have  been  described  as  Bednar's  aphtha?,  or  plac[ues  pterygo'idiennes  by 
Parrot.  They  are  produced  by  the  pressure  of  the  back  of  the  tongue  against 
the  hard  palate  in  sucking.     They  have  nothing  to  do  with  syphilis. 

The  treatment  must  depend  upon  the  cause,  whether  the  stomatitis 
depends  upon  dentition,  gastro-intestinal  catarrh,  or  other  pathological  con- 
dition. In  most  cases  a  mild  purge  will  be  useful  to  expel  any  indigestible 
food  present  in  the  alimentary  canal,  to  be  followed  by  some  small  doses  of 
rhubarb  and  soda.  It  is  doubtful  if  chlorate  of  potash  is  of  any  use  in  this 
form. 

Locally  the  spots  may  be  touched  with  a  solution  of  permanganate  of 
potash  (5  grs.  to  the  oz.)  or  boric  acid  (15  grs.  to  the  oz.).  If  the  spots  are 
slow  in  healing,  they  may  be  touched  with  lapis  divinus.  This  latter  consists 
of  equal  parts  of  sulphate  of  copper,  alum,  and  saltpetre  fused  together.  The 
diet  should  consist  of  milk  and  barley  water  made  more  dilute  than  usual, 
and  for  older  children  milk  and  sops.  Beef  tea  and  saline  fluids  are  generally 
objected  to  on  account  of  causing  smarting  in  the  mouth.     (F.  5,  F.  6.) 

Parasitic  Stomatitis.  Thrush. — This  form  of  stomatitis  differs  essen- 
tially from  the  forms  already  described,  as  it  is  clue  to  the  presence  and  growth 
in  the  epithelium  of  the  mouth  of  a  species  of  cryptogam.  It  is  especially 
common  in  newly  born  infants  and  in  those  of  a  few  months  old,  who  are 
suffering  from  some  form  of  wasting  disease,  and  in  whom  the  mucous 
membrane  of  the  mouth  is  in  an  unhealthy  condition.  But  it  is  also  found  in 
infants  during  the  last  half  of  the  first  year,  less  cornmonly  during  the  second 
and  later  years.    It  appears  as  small  white  distinctly  raised  points  or  scattered 

F 


66 


Diseases  of  the  Digestive  System 


patches  on  the  soft  palate,  mucous  membrane  of  the  cheek,  h'ps,  and  tongue. 
While  its  chief  seat  is  the  mouth,  it  has  been  found  in  the  larynx,  oesophagus, 
stomach,  Ccecum,  and  in  one  or  two  instances  in  the  lungs.  If  touched  with 
a  small  paint-brush,  the  patch  is  found  to  adhere  firmly  to  the  mucous 
membrane  and  cannot  be  detached  as  can  milk  flocculi,  for  which  it  may 
readily  be  mistaken  ;  if  forcibly  detached  there  is  left  a  red  surface  denuded 
of  epithelium.  The  mucous  membrane  of  the  mouth  is  often  red  and 
unhealthy  around  the  patches,  in  other  cases  it  is  quite  normal.  In  mild 
cases  these  white  patches  are  small  and  few  in  number  ;  in  severe  cases  they 
become  confluent  and  large,  and  the  surface  of  the  tongue  and  cheeks  is 
covered  with  them.  Infants  so  affected  are  mostly  weak  and  ill,  and  often 
suffer  from  diarrhcea  or  gastric  catarrh  with  wasting.  It  occurs  in  older 
children  in  the  last  days  of  tuberculosis,  tubercular  meningitis,  typhoid,  and 
pneumonia. 

If  a  piece  of  the  white  patch  be  detached  and  examined  microscopically, 
it  will  be  found  to  consist  of  epithelial  cells,  bacteria,  yeast  fungi,  and  the 

thread-like  filaments  of  various 
mould  fungi.  The  identity  of  the 
fungus  which  gives  rise  to  the 
disease  is  a  matter  of  uncertainty, 
the  difficulty  of  identifying  it  being 
largely  due  to  the  presence  of 
various  organisms  in  the  white 
patches.  It  has  been  identified 
as  the  Oidium  lactis,  the  mould 
fungus  which  is  present  in  sour 
milk  ;  the  cultivations  of  Grawitz 
led  him  to  believe  it  to  be  identical 
with  the  yeast  fungus  or  wine  fer- 
ment {^Saccharoniyces  mycoderma). 
Rees,  who  further  investigated  it, 
believes  it  to  be  a  yeast  fungus, 
though  not  identical  with  the  above  ;  he  gave  it  the  name  of  Saccha- 
roniyces  albicans.  The  micro-organism  of  thrush  is  most  probably,  as 
Fraenkel  states,  a  link  between  the  yeast  fungi  {Saccharomyceies)  and  the 
mould  or  thread  fungi  {Hypomycetes).  It  can  be  cultivated  in  syrup,  gelatine, 
or  potatoes  and  bread  paste  ;  under  certain  conditions  of  nutrition  it  appears 
to  resemble  the  yeast  fungi,  as  on  the  surface  of  the  gelatine  ;  while  at  the 
bottom  of  the  test-tube  cultures  it  appears  more  like  the  thread-like  forms  of 
the  mould  fungi.     It  is  aerobic,  and  does  not  liquefy  gelatine. 

The  fungus  usually  appears  in  the  form  of  filaments  made  up  of  cells 
jointed  together  3-4  /a  broad  and  50-60  /n  long  ;  these  branch  in  various 
directions  ;  oval  cells  bud  out  from  the  joint  between  the  elongated  cells  ; 
spores  are  present  in  these  roundish  cells.     (See  fig.  11.) 

Treatment. — ^It  is  of  much  importance  that  great  care  should  be  taken  to 
cleanse  the  mouth  after  the  infant  has  taken  the  bottle,  especially  in  a  weakly 
infant  of  low  vitality,  weak  alkaline  solutions,  just  tinged  with  Condy's  Fluid, 
being  useful  for  this  purpose.  This  can  be  done  with  a  large  paint-brush  or 
soft  wet  rag,  and  on  the  first  symptoms  of  thrush  the  borax  lotion  (F.  3)  or 


;. — Fungus  of  thrush  (x  300). 
(A/ter  Crookshank.) 


Parasitic  Stomatitis — Thrush  6y 

similar  solution  should  be  used.  As  a  stronger  application  to  the  parasitic 
patches  a  solution  of  sulphate  of  copper  (2  grs.  to  the  02.  j  or  carbolic  acid 
(2  grs.  to  the  oz.)  is  very  effectual  when  applied  with  a  paint-brush.  The 
success  of  the  treatment  depends  not  only  on  the  destruction  of  the  fungus 
but  also  on  an  improvement  in  the  child's  general  health.     (F.  5,  F.  6.) 

Haexnorrliag'ic  Stomatitis  occurs  in  infantile  scurvy.     (See  p.  192.) 

ITlcerative  Stomatitis. — This  form  only  occurs  in  children  who  have  cut 
teeth,  and  is  most  common  after  the  molars  have  been  cut.  It  occurs  in  chil- 
dren both  with  healthy  and  also  with  carious  teeth.  The  children  who  suffer 
from  it  in  the  severe  form  are  unhealthy,  and  are  either  recovering  from  some 
infectious  disease,  or  have  been  badly  fed,  or  have  been  exposed  to  unhealthy 
surroundings  ;  it  is  also  common  in  tuberculous  children.  The  early  symp- 
toms are  feverishness,  salivation,  and  smarting  when  food  or  drink  is  taken. 
When  the  attack  is  developed,  an  examination  of  the  mouth  will  show  that 
the  gums  are  much  swollen  and  tender,  and  a  purulent  secretion  is  present 
along  their  free  edges.  The  breath  is  foul,  and  some  bleeding  takes  place 
from  the  swollen  gums.  The  ulceration  may  extend  to  the  mucous  membrane 
of  the  cheek,  especially  that  part  contiguous  to  the  lower  molars.  Here  a 
deep  ulcer  with  a  yellow  base  may  often  be  seen,  and  the  tissure  between  the 
cheek  and  gums  may  also  be  involved.  The  side  of  the  tongue  is  affected  in 
some  cases.  Bernheim  has  recently  described  two  micro-organisms,  a 
bacillus  and  spirochaete,  which  he  believes  to  be  specific.  Ulcerative 
stomatitis  appears  at  times  to  be  epidemic  and  contagious. 

Necrosis  of  the  jaw  is  apt  to  follow  in  some  of  the  more  severe  cases  of 
ulcerative  stomatitis  ;  instead  of  the  process  ceasing,  as  it  usually  does,  the 
mischief  spreads  and  a  chronic  osteomyelitis  of  the  jaw  is  set  up,,  much 
intensely  foetid  discharge  comes  away,  the  child's  health  suffers,  the  cheeks 
become  puffy  and  flabby,  the  ulceration  of  the  gums  spreads,  and  after  a 
while  it  is  found  that  a  large  piece  of  jaw,  carrying  perhaps  two  or  three  teeth, 
is  loose  ;  if  this  is  taken  away,  in  some  instances  the  process  stops  ;  often, 
however,  any  new  bone  that  may  have  formed  becomes  infiltrated  with  the 
foul  discharges,  and  the  mischief  spreads  along  the  jaw,  piece  after  piece  is 
taken  away,  until  at  last  the  entire  jaw  may  have  to  be  removed.  We  have 
removed  the  whole  bone  from  condyle  to  condyle  for  this  condition.  Many 
surgeons  believe  that  the  disease  begins  as  a  periostitis  and  not  as  an  ulcera- 
tion of  the  gums,  and  that  alveolar  abscess  is  the  starting-point  ;  this  maybe 
so  sometimes,  though  certainly  not  always.  ^ 

The  child's  health  materially  suffers  from  the  discharge  and  foul  state  of 
the  mouth.  In  one  instance,  after  removal  of  the  jaw,  the  child  was  sent  home 
.  convalescent,  but  died  suddenly,  apparently  from  falling  back  of  the  tongue. 
Restoration  of  the  jaw  is  very  imperfect  in  these  cases,  for  the  new  bone 
necroses  as  fast  as  it  forms.  The  process  closely  i-esembles  phosphorus 
necrosis,  but  it  is  not  due  to  that  poison. 

Treatment. — After  every  meal  the  mouth  should  be  well  rinsed  with 
warm  water  or  Condy's  Fluid,  and  the  gums  and  teeth  cleaned  with  a  bit  of 
absorbent  wool  or  soft  rag,  not  sponge,  so  that  the  same  bit  may  never  be 
used  again  ;    the  gums  should  then  be  mopped  over  with  the  glycerine  of 

1  Dr.  Angel  Money  has  reported  a  case  coming  on  after  typhoid  and  affecting  the  upper 
jaw.     The  lower  jaw  is  the  one  niost  commonly  attacked. 

I"  2 


68  Diseases  of  the  Digestive  System 

borax  2  parts  to  tincture  of  myrrh  i  part.  Of  internal  remedies,  by  far  the 
most  efficient  is  chlorate  of  potash,  given  in  three  to  five  grain  doses  three 
times  a  day  or  more.  In  the  large  majority  of  cases  this  if  given  early  will 
quickly  cure  the  disease — twenty  or  twenty-five  grains  in  the  twenty-four  hours 
is  a  safe  amount  to  give,  but  should  not  be  continued  for  more  than  a  week. 
It  may  be  followed  by  an  iron  tonic.  The  diet  should  consist  of  fluids  and  sops, 
beef  tea  and  other  nourishing  Hquids  being  given  freely,  especially  in  those 
cases  where  the  disease  occurs  in  the  poorly  nourished  and  underfed.  This 
treatment  will  usually  suffice  to  arrest  the  disease  ;  but  once  the  bone  becomes 
seriously  involved,  in  some  cases  nothing  seems  to  have  any  effect.  Strong 
nitric  acid,  carbolic  acid,  &c.,  seem  to  have  httle  power,  and  the  purulent 
infiltration  only  ceases  when  the  whole  bone  has  been  destroyed.  These  plans 
should,  however,  be  carefully  tried,  chloroform  being  of  course  given,  and 
subsequently  there  should  be  very  frequent  cleansing  of  the  mouth  with  equal 
parts  of  rectified  spirit  and  water.  As  soon  as  the  disease  has  ceased  to 
spread,  any  loss  of  bone  or  teeth  should  be  supplied  by  a  plate  with  artificial 
teeth,  to  prevent  falling  in  of  the  lips  and  the  prematurely  senile  appearance 
thus  produced.  Even  where  the  alveolus  alone  is  destroyed,  since  no  new 
formation  of  bone  occurs  the  permanent  teeth  are  often  loosened  and  fall 
out.    (F.4,  F.3,  F.  5.) 

Alveolar  iibscess  is,  as  might  be  expected,  a  very  common  result  of  the 
neglect  or  mismanagement  of  carious  teeth.  After  an  attack  of  toothache 
the  pain  may  completely  subside,  and  swelling  of  the  face  over  either  the  upper 
or  lower  jaw  rapidly  come  on.  This,  of  course,  means  that  the  inflammatory 
process — hitherto  limited  to  the  alveolus,  and  hence  giving  rise  to  great 
pain,  because  there  is  great  tension  on  a  large  nerve — has  extended  to 
the  soft  parts  covering  the  bone  by  escape  of  the  pus  from  the  alveolus. 
The  pain  is  greatly  lessened,  or  ceases  altogether.  The  condition  is  thought 
of  little  importance,  and  no  steps  are  taken  to  obtain  advice,  as  there  is 
no  longer  pain,  and  a  swelled  face  is  looked  upon  as  the  natural  and  proper 
ending  of  a  toothache.  No  doubt  most  of  these  cases  get  perfectly  well 
at  least  for  a  time,  for  the  abscess  bursts  either  by  the  side  of  the  tooth 
or  more  often  through  the  alveolus  and  gum,  and  discharges  itself  into 
the  mouth.  Finally,  the  abscess  closes  up,  and  all  remains  quiet  till  some 
failure  of  health  or  some  irritation  rouses  the  carious  tooth  to  another 
outbreak.  In  not  a  few  cases,  however,  neglect  to  remove  the  source  of 
irritation — i.e.  the  carious  tooth — gives  rise  to  one  or  other  of  the  following 
troubles.  Often  a  sinus  remains  inside  the  mouth  leading  through  the 
alveolus  to  the  fang  of  the  dead  tooth,  and  a  constant  discharge  of  a  small 
quantity  of  foul  pus  takes  place  within  the  mouth.  Such  a  condition  cannot 
but  be  prejudicial  to  a  child's  health.  The  breath  is  foul,  and  the  foul  fluid 
is  swallowed,  poisoning  alike  the  lungs  and  stomach,  and  often  a  child  is 
kept  ailing  for  months,  for  want  of  extraction  of  a  carious  tooth.  In  other 
cases,  the  abscess  tracks  to  the  surface  and  is  allowed  to  burst  there,  giving 
rise  often  to  a  lifelong  disfigurement,  in  the  shape  of  a  depressed  scar  over 
upper  or  lower  jaw.  Or,  again,  a  chain  of  enlarged  lymphatic  glands  or  a 
glandular  abscess  owes  its  origin  to  neglect  of  a  carious  tooth  or  alveolar 
abscess.  Necrosis  of  the  jaw  often  results  from  similar  neglect.  Occasionally, 
too,  we  see  cases  of  antral  abscess  in  children  as  a  result  of  extension  of 


Alveolar  Abscess 


69 


mischief  from  a  tooth,  though  it  is  perhaps  less  common  in  children  than  we 
might  expect.  There  is  a  most  unreasonable  objection  both  on  the  part  of 
parents  and  of  some  dentists  to  extraction  of  teeth,  even  if  they  are  ex- 
tensively carious,  and  even  if  they  are  only  temporary  teeth.  It  is  difficult 
to  believe  that  the  retention  of  a  dead  or  carious  temporary  tooth  can  do  any- 
thing but  harm  to  the  jaw  and  the  underlying  permanent  teeth.  It  is  perhaps 
still  more  difficult  to  understand  the  principle  on  which  objection  is  made 
to  the  removal  of  a  tooth  while  there  is  an  abscess  present,  yet  it  often  hap- 
pens that  delay  is  urged  till  the  abscess  is  well.  In  all  cases  a  carious 
temporary  tooth  should  be  removed  at  the  least  sign  of  inflammation  about 
it  or  if  it  causes  foul  breath.  In  all  cases  a  tooth  that  has  given  rise  to  an 
alveolar  abscess  should  be  removed,  and  if  its  extraction  does  not  empty 
the  abscess  a  free  opening  should  be  made  inside  the  mouth,  and  the  abscess 
cavity  and  whole  mouth  frequently 
washed  out  with  some  antiseptic  lotion 
till  all  is  well  again.  On  no  account 
should  an  abscess  be  allowed  to  track 
towards  the  surface  of  the  face,  nor 
should  any  tooth  be  allowed  to  remain 
in  the  jaw  with  a  sinus  leading  down  to 
its  fang.  If  antral  abscess  is  met  with 
or  necrosis  of  the  jaw,  they  must  be 
dealt  with  by  the  ordinary  methods, 
bearing  in  mind  the  softness  and  thin- 
ness of  children's  bones.  We  had  in 
1895  under  our  care  a  child  with  exten- 
sive tubercular  disease  of  both  antra, 
which  probably  arose  from  the  irritation 
of  carious  teeth. 

Gangrenous  Stomatitis.  Cancrum 
Oris. — Cancrum  oris  occurs  almost  in- 
variably in  squalid,  half-starved  children 
after  one  of  the  exanthemata  ;  some- 
times, however,  it  seems  to  have  no 
such  predisposing  cause.  The  disease 
begins  as  an  inflamed  spot  on  the  inner  surface  of  the  cheek  or  upon  the 
gum,  the  mischief  rapidly  spreads,  both  in  depth  and  area,  and  the  whole 
thickness  of  the  cheek  and  gum  becomes  involved.  On  the  outer  surface  the 
cheek  is  swollen,  shining,  stiff,  and  pale,  or  sometimes  dark  red,  its  vessels 
are  thrombosed,  and  soon  a  black  spot  appears  in  the  centre  of  the  pale 
waxy  area  ;  the  cheek  is  perforated,  the  black  spot  becomes  a  definite  slough 
which  partially  separates.  Then  the  edges  of  the  gap  become  black  and  the 
sloughing  spreads,  preceded  by  a  zone  in  which  the  skin  is  pale  and 
cedcmatous.  In  severe  cases  the  whole  side  of  the  face  is  rapidly  destroyed, 
the  gums  slough  away,  the  jaw  necroses,  and  the  teeth  drop  out.  There  is 
intense  foetor  of  the  discharge  and  breath,  which  poisons  the  child,  frequently 
causing  pneumonia  and  death  before  the  process  is  complete.  Sir  S.  Wilks 
considers  that  when  the  sloughing  attacks  the  gum  first  it  may  be  only  an 
aggravated  form  of  the   ulceration   met  with   in  a   late  condition  of  scarlet 


Fig.  12. — Deformity  resulting  after  recovery 
from  cancrum  oris  ;  subsequently  remedied 
by  a  plastic  operation.  Dr.  Wilkinson's  case. 


yo  '  Diseases  of  the  Digestive  System 

fever  ;  this  is  seen  usually  in  the  lower  jaw,  while  in  true  cancrum  oris  the 
upper  jaw  is  attacked.' 

In  a  fair  number  of  instances  the  process  is  arrested  and  the  sloughing 
ceases,  the  parts  clean  up  and  heal  rapidly,  leaving,  of  course,  a  more  or 
less  severe  deformity.  In  fatal  cases  death  is  due  to  exhaustion  or  septic 
pneumonia.  The  amount  of  pain  and  distress  suffered  is  variable,  sometimes 
but  httle  of  either  exists. 

Treatment. — The  treatment  of  cancrum  oris  consists  in  the  free  local 
application  of  the  actual  cautery,  or,  better,  of  pure  nitric  acid.  The  child 
should  be  put  under  chloroform  and  the  parts  carefully  dried  with  lint ; 
sticks  dipped  in  strong  nitric  acid  should  then  be  rubbed  well  into  the 
edges  of  the  sloughing  parts  and  over  the  surface  of  the  gums,  after  cutting 
away  any  loose  sloughs  and  removing  sequestra.  Care  must,  of  course,  be 
taken  not  to  allow  the  acid  to  run  over  the  sound  skin.  Several  applica- 
tions of  the  acid  should  be  made,  the  parts  being  dried  after  each.  After- 
wards, a  little  iodoform  should  be  powdered  on  and  the  surface  smeared 
well  with  carbolic  oil.  E.  C.  Kingsford  has  had  good  results  from  the  appli- 
cation of  perchloride  of  mercury,  but  it  has  not  proved  universally  successful.- 
No  less  important  than  the  local  treatment  is  the  free  administration  of 
stimulants  and  abundant  nourishment.  As  much  wine  or  brandy  as  the 
child  will  take  (about  3-4  ounces  of  brandy  in  twenty-four  hours  for  a  child 
of  five  years),  carbonate  of  ammonia  and  bark,  eggs  beaten  up  with  milk, 
strong  soup  and  meat  extracts  should  be  given.  In  these  cases,  as  in 
phlegmonous  erysipelas,  patients  seem  to  be  able  to  take  almost  an  un- 
limited amount  and  to  thrive  on  it.  Opium  should  be  given,  but  with 
caution,  as  it  is  not  always  well  borne.  If  the  child  recovers,  the  deformity 
is  often  remediable  to  a  considerable  extent  by  a  plastic  operation.  Perhaps 
the  most  troublesome  after  condition  is  closure  of  the  mouth  by  adhesions  ; 
an  attempt  to  prevent  this  should  be  made  during  healing  by  the  use  of 
screw  gags  or  mouth-openers,  and  later,  by  division  of  the  scar  tissue  ;  in 
some  cases  even  section  of  the  jaw  and  the  establishment  of  a  false  joint 
may  be  required.  It  must  be  confessed,  however,  that  the  treatment  of 
this  cicatricial  contraction  is  far  from  satisfactory,  and  often  no  permanent 
good  result  is  obtained. 

Some  cases  of  cervical  cellulitis  (so-called  angina  Ludovici)  closely  re- 
semble cancrum  oris  in  their  results.     (See  p.  245.) 

Acute  Tonsillitis. — It  is  hardly  possible  to  exaggerate  the  importance 
of  a  thorough  examination  of  the  throat  of  a  feverish  child,  especially  when 
the  cause  of  its  illness  is  not  obvious.  A  child,  more  particularly  a  young  one, 
does  not,  like  an  adult,  volunteer  the  information  that  its  throat  is  sore  and 
painful  during  the  act  of  swallowing,  and  will  even  deny  that  it  is  sore  when 
it  is  actually  suffering  from  severe  tonsillitis.  Without  a  careful  examina- 
tion it  is  quite  possible  to  overlook  not  only  tonsillitis  but  scarlet  fever  or 
diphtheria,  especially  if  there  is  some  chest  complication  present  to  throw 
the  observer  off  his  guard  ;  or  he  may  come  to  the  conclusion  that  a  case  of 
submaxillary  '  mumps,'  or  croupous  pneumonia  with  physical  signs  delayed, 

1  An  excellent  description  and  figure  are  given  in  Mr.  Cooper  Forster's  book  on  the 
Surgical  Diseases  of  Children. 

2  Lancet,  Sept.  1891. 


A  CH  te   Tonsillitis 


71 


is  a  case  of  scarlet  fe\er.  Any  one  who  has  had  any  experience  of  a  fever 
hospital  will  be  able  to  call  to  mind  many  cases  where  errors  have  been 
made  through  neglecting  to  examine  the  tonsils  or  from  want  of  knowledge 
of  their  appearance  in  health  and  disease. 

Children  are  very  liable  to  tonsillitis  in  its  broadest  sense,  and  this  is  in 
harmony  with>the  fact  that  the  lymphatic  system  during  childhood  is  ex- 
tremely active  and  especially  prone  to  inflammation.  The  use  which  the 
tonsils  fulfil  is  uncertain,  but,  whatever  their  exact  function,  it  is  certain 
that  they  belong  to  the  lymphatic  system,  and  they  have  been  justly  com- 
pared to  Peyer's  patches,  inasmuch  as  they  I'esemble  them  in  structure,  con- 
sisting of  congeries  of  lymph  follicles  or  so-called  'solitary  glands.'  They 
have  a  large  blood  supply,  and  their  lymph  sinuses  freely  communicate 
with    the    lymphatics  of  the  mouth  and  pharynx,  and  also  with    the  deep 


g.  13.  "Vertical  section  of  human  tonsil  (x  20),  Landois  and  Stirling. 
I,  cr^-pt  ;  2,  epithelium  infiltrated  with  leucocj'tes  below  and  on  the  left, 
but  free  on  the  right  ;  3,  adenoid  tissue  with  sections  _/J_/5_/^  of  lymph  folli- 
cles ;  4,  fibrous  sheath  ;  5,  section  of  mucous  gland  duct  ;  6,  blood-vessel. 


cervical  glands  situated  behind  the  angle  of  the  jaw.  Their  surfaces  are 
covered  with  deep  clefts  or  crypts  which  serve  to  increase  the  surface  of  the 
mucous  membrane  covering  them  ;  these  are  apt  to  become  filled  with  thick 
yellowish  secretion,  and  are  then  seen  as  yellow  points  scattered  over  the 
surface.  One  of  the  functions  of  the  tonsils  is  probably  the  formation  of 
leucocytes,  or  white-blood  corpuscles,  which  are  shed  into  the  salivary  secre- 
tion, and  the  cheesy  secretion  formed  during  inflammation  consists  princi- 
pally of  these  bodies.  Tonsillitis  occurs  under  the  influence  of  many  different 
conditions  during  childhood,  and  possibly  the  proneness  of  the  tonsils  to 
inflame  is,  in  part  at  any  rate,  the  result  of  their  position  at  the  entrance  of 
the  fauces,  where  the  various  forms  of  aerial  poisons,  bacilli  or  other  germs, 
would,  when  inhaled,  be  especially  likely  to  lodge.  Many  of  the  zymotic 
diseases  are  accompanied,  or,  what  is  a  very  significant  fact,  are  preceded. 


72  Diseases  of  the  Digestive  System 

by  tonsillitis.  Thus  the  tonsils  are  the  seat  of  inflammation  in  scarlet  fever 
and  diphtheria.  Typhoid  fever  and  influenza  sometimes  commence  with  sore 
throat,  measles  and  rotheln  are  mostly  attended  with  some  congestion  or 
catarrhal  inflammation  about  the  fauces.  The  tonsils  are  apt  to  become  in- 
flamed as  the  result  of  cold,  as  from  a  wetting  or  exposure  to  a  draught  or 
keen  east  wind,  and  possibly  also  from  some  gastric  disturbance.  There  can 
be  little  doubt  also  that  tonsillitis  is  at  times  due  to  inhaling  sewer  gas  or 
unwholesome  smells.  It  also  appears  sometimes  to  precede  or  accompany 
an  attack  of  acute  rheumatism,  or  peri-endocarditis. 

The  record  of  tonsillar  complication  is  not  complete  without  reference 
to  the  epidemics  of  sore  throats  which  are  apt  to  occur  in  schools,  hospitals, 
and  other  public  institutions,  or  wherever  many  children  are  brought 
together.  Some  of  these  epidemics  have  appeared  to  be  modified  scarlet 
fever,  diphtheria,  or  influenza,  as  proved  by  their  belonging  to  a  scarlatinal 
or  diphtheritic  epidemic  which  was  coexistent  in  the  neighbourhood  or  pre- 
ceded or  followed  the  epidemic  of  sore  throats.  But  in  other  cases  it  has 
been  clearly  shown  that  there  is  an  epidemic  or  infectious  form  of  sore  throat 
which  closely  resembles  both  scarlet  fever  and  diphtheria,  but  which,  while 
similar  in  many  respects,  is  actually  distinct,  as  shown  by  its  not  protecting 
from  either  of  the  above  diseases.^  In  some  of  these  attacks  of  tonsillitis, 
streptococci,  pneumo-cocci,  colon-bacilli,  and  other  organisms  have  been 
found.  Some  cases  of  epidemic  sore  throat  have  apparently  been  traced  to 
the  consumption  of  the  milk  of  cows  sufifering  from  '  foot  and  mouth  '  disease. 
Whenever  sore  throats  occur  in  a  household  or  school,  the  possibility  that 
they  are  the  result  of  the  scarlatinal  or  diphtheritic  poison  should  always  be 
kept  in  view,  Avhile  at  the  same  time  the  milk  supply  and  the  sanitary 
condition  of  the  establishment  should  be  carefully  investigated. 

To  whatever  cause  the  tonsillitis  is  due,  whether  sporadic  or  epidemic, 
the  symptoms  are  mostly  the  same.  The  attack  usually  begins  suddenly, 
though  it  is  often  preceded  for  a  few  hours  by  a  feeling"  of  soreness  in  swallow- 
ing. Unlike  scarlet  fever,  it  is  usually  unattended  by  vomiting  ;  the  evening 
temperature  runs  up  to  103°  or  more,  the  tonsils  are  swollen  and  red,  there 
is  much  secretion  of  mucus,  and  in  a  few  hours  yellow  points  make  their 
appearance  upon  the  tonsils,  the  result  of  secretion  retained  in  the  crypts. 
(See  fig.  14.)  The  tongue  is  furred,  but  does  not  become  of  a  '  strawberry  ' 
appearance  as  in  scarlet  fever.  In  some  cases,  instead  of  the  yellow  points 
seen  on  the  tonsils  there  is  a  yellowish  exudation  formed  by  the  coalescence 
of  the  yellow  spots  on  the  inner  surfaces  of  the  tonsils  ;  this  does  not  adhere, 
as  a  rule,  with  any  degree  of  firmness,  and  may  be  removed  with  a  brush. 
The  inflammatory  lesion  remains  for  the  most  part  tonsillar,  and  shows  but 
little  tendency  to  spread  and  involve  the  nasal  mucous  membrane  or  the  middle 
ear,  and,  while  the  glands  at  the  angle  of  the  jaw  may  become  enlarged, 
they  are  not  hard  or  surrounded  by  celluHtis.  There  is  no  true  ulceration  of 
the  tonsils  or  sloughing  of  the  palate.  The  temperature  remains  remittent 
for  a  few  days,  gradually  returning  to  normal. 

Such  is  the  clinical  history  of  an  attack  of  acute  catarrhal  tonsillitis,  but 
it  must  be  remembered  that  many  such  attacks  are  exceedingly  mild,  and 
are   accompanied  by   but    little  pyrexia,   and  may   perhaps   come  and   go 
1  Vide  Tonsillitis  in  Adolescents,  by  C.  Haig-Brown,  M.D. 


Acute   Tonsillitis 


71 


without  much  comphiint  bcinjf  made  about  them.  Acute  tonsillitis  from  any 
cause  is  apt  to  leave  the  tonsils  enlarged,  and  the  mucous  membrane 
covering  them  in  a  condition  of  chronic  catarrh.  Repeated  attacks  in 
children  liable  to  glandular  swellings,  accompanied  as  they  are  by  catarrh 
of  the  naso-pharynx  in  many  cases,  give  rise  to  various  troubles  which  will 
be  described  later  on. 

Diagnosis. — The  most  important  question  to  consider,  when  called  to 
see  a  case  of  tonsillitis,  is  whether  scarlet  fever  and  diphtheria  may  be 
e.xcluded  with  certainty  ;  as,  if  they  can,  it  is  tolerably  certain  tha,t  the  case  is 
not  one  which  will  give  rise  to  any  anxiety  either  on  account  of  the  patient 
himself  or  his  friends.  Unfortunately,  however,  it  is  not  often  possible  to 
express  an  opinion  without  misgivings  ;  that  which  appears  to  be  a  simple 
tonsillitis  may  be  scarlatinal  or  diphtheritic  in  origin.      It  need  hardly  be  said 


^ 

■n 

r 

IBB 
1 1 

im 

n 

I 

n 

\  1 

1 

uin  1    fin 

n 

% 

H 

1 

■  i  n 

II 
II 

fi 

SH 

1 

u 

1 

BiiB 

Ml    1 

LIV 

n 

iin 

n 

1 

Eli 

■■li 

■1 

U 

01 

mm 

nil 

■nni 

■I 

1 

Sfl 

l>B 

SB 

III 

Hii 

Hi 

nil 

nm 

iiii 

iiin 

III 

mill 

ini 

HH 

Fig.  14. — Acute  Tonsillitis,  a,  child  aged  three  years  ;  b,  child  aged  four  years.  These 
two  cases  belonged  to  an  epidemic  of  sore  throats  ;  scarlet  fever  was  not  certainly 
e.xcluded,  but  in  no  case  was  there  a  rash. 


that  the  child  suffering  from  tonsillitis  should  be  stripped  and  a  careful 
examination  made  of  the  surface  of  the  body  by  a  good  light  in  order  to 
detect  a  rash,  and  the  faintest  rash  would  necessarily  arouse  suspicion.  In 
the  absence  of  a  rash  a  certain  diagnosis  is  often  impossible,  but  glandular 
enlargement,  discharge  from  the  nose,  much  redness  of  the  fauces  with 
yellow  exudation  on  the  tonsils,  true  ulceration  of  the  tonsils  or  soft  palate 
or  otitis,  if  present,  would  make  the  diagnosis  of  scarlet  fever  a  probable  one. 
Should  desquamation  follow,  if  it  is  certain  there  has  been  no  rash,  it  is  of  no 
diagnostic  importance.  If  nephritis  occur  jn  the  third  week,  it  points  to  the 
scarlatinal  nature  of  the  attack  as  beyond  doubt.  A  strawberry  tongue  is 
rarely  present  in  the  absence  of  a  rash.  The  difficulty  of  diagnosis  between 
mild  diphtheria  and  tonsillitis  accompanied  by  greyish  exudation  is  hardly 
less  than  that  between  tonsillitis  and  scarlet  fever  in  the  absence  of  a  rash. 


74  Diseases  of  the  Digestive  System 

Albuminuria,  nasal  discharge,  glandular  enlargement  and  cellulitis,  and  the 
presence  of  Loeffler's  bacillus  in  the  exudation,  all  point  to  diphtheria  ;  if 
paralysis  follow,  the  diagnosis  of  diphtheria  is  certain.  In  all  doubtful  cases 
a  swab  should  be  taken  of  the  secretion  and  submitted  for  bacterial  exami- 
nation.    (See  Diphtheria.) 

Treatment. — Every  attack  of  tonsillitis  during  childhood  should  be 
treated  not  only  with  respect  but  with  suspicion,  and  the  case  should  at 
once  be  isolated  as  far  as  it  is  possible  to  do  so.  It  should  constantly  be 
before  the  mind  of  the  practitioner  that  the  case  may  be  one  of  abortive 
scarlet  fever  or  diphtheria,  and  that  the  next  case  to  which  he  is  called  in  the 
same  household  may  be  a  genuine  attack  of  one  of  the  above  zymotic  diseases. 
It  is  always  wise,  when  called  to  such  cases,  to  give  a  guarded  diagnosis 
and  prognosis  until  the  case  has  been  under  observation  for  a  few  days. 
The  patient  is  to  be  confined  to  his  room  or  to  his  bed,  according  to  the 
severity  of  the  attack,  and  his  diet  should  consist  of  milk,  beef  tea,  and  sops. 
If  there  is  much  pain  in  swallowing,  hot  fomentations  medicated  with  bella- 
donna or  opium  may  be  applied  externally  and  renewed  at  frequent  intervals. 
The  tonsils  should  be  painted  with  a  solution  of  boro-glyceride  in  water 
(1-12),  or  iodine  gr.  ij,  glycerine  5j)  and  water  §j  ;  black  currant  jelly  or 
lozenges  are  also  useful.  Salines,  such  as  the  citrates  or  chlorates  of  the 
alkalies,  combined  with  aconite  or  salicylate  of  soda,  if  there  is  much  fever, 
may  be  given  during  the  febrile  stage  ;  acids  and  cinchona  during  con- 
valescence.    (F.  7,  F.  8,  F.  9,  F.  10.) 

Chronic  Tonsillitis. — So-called  chronic  tonsillitis,  or  tonsillar  hyper- 
trophy, is  a  very  important  child's  disease,  though  by  no  means  limited 
to  childhood.  The  affection  consists  in  an  actual  overgrowth  of  the  tonsillar 
adenoid  tissue,  so  that  the  tonsils  become  greatly  enlarged  and  project  as 
rounded  or  irregular  masses  in  various  directions.  Most  commonly  they 
grow  inwai'ds  towards  the  middle  line,  and  may  reach  such  a  size  as  to  meet 
and  be  flattened  by  mutual  pressure ;  they  may  then  almost  completely  block 
the  orifice  of  the  pharynx.  In  other  instances  they  enlarge  vertically  and 
become  large  oval  masses,  projecting  far  down  into  the  pharynx  and  upwards 
and  backwards  towards  the  posterior  nares.  In  other  cases  again  they 
protrude  outwards,  separating  the  layers  of  the  soft  palate  and  forming  a 
bulging  mass  on  the  roof  of  the  mouth.  Sometimes  the  surface  is  almost 
smooth,  marked  only  by  the  orifices  of  the  tonsillar  crypts,  and  sometimes  it 
is  quite  rugged  and  irregular. 

The  causes  of  chronic  enlargement  of  the  tonsils  are  probably  the  various 
irritations,  mechanical  and  other,  to  which  they  are  exposed,  just  as  in  the 
case  of  masses  of  lymph  gland  tissue  elsewhere. 

The  overgrowth  is  often  accompanied  by  recurrent  attacks  of  acute  in- 
flammation, in  other  cases  there  is  no  pain  or  acute  distress  at  any  time. 
The  secretion  of  the  mucous  glands  may  be  retained,  and  thick  pellets  of 
inspissated  matter  be  shut  up  in  the  crypts.  Occasionally,  on  examining 
the  region  of  the  tonsil,  instead  of  the  usual  appearance,  a  large  yellow  mass 
will  be  seen  blocking  up  the  whole  of  that  side  of  the  pharynx  :  it  is  soft  and 
fluctuating,  and  on  incision  gives  exit  to  a  large  quantity  of  thick  debris  of 
mucus,  pus,  cholesterine,  &c.  This  condition  we  have  sometimes  thought 
to  be  a  congenital  mucoid  cyst.     It  is  rather  alarming  at  first  sight,  and  looks 


Chronic   Tonsillitis  75 

like  a  large  abscess  on  the  point  of  bursting.     The  symptoms  are  those  of 
tonsillar  hypertrophy  with  more  or  less  dysphagia. 

The  ordinary  enlarged  tonsil  is  usually  pale,  and  in  old  cases  hard  and 
sometimes  almost  cretaceous.  The  enlargement  may  be  found  at  any  age 
from  birth  (being  sometimes  congenital)  to  puberty,  or  more  rarely  later  ;  it 
gives  rise  to  a  definite  series  of  symptoms,  all  or  most  of  which  are  usually 
present  together.  There  is  a  vacuous,  heavy  look,  from  obstruction  to 
breathing  and  consequent  imperfect  aeration  of  the  blood,  also  imperfect 
development,  and  often  stunting  of  growth  ;  the  mouth  is  kept  open,  the 
breathing  is  stertorous  and  in  sleep  snoring.  These  children  usually  sleep 
heavily  but  restlessly,  often  starting  in  their  sleep  ;  incontinence  of  urine  is 
sometimes  present,  a  result,  no  doubt,  of  the  supply  of  imperfectly  aerated 
blood  to  the  nervous  centres.  There  is  usually  chronic  nasal  and  often 
aural  catarrh,  from  the  e.Ktension  of  irritation  from  the  tonsils  to  the  neigh- 
bouring mucous  surfaces.  The  speech  is  nasal  and  indistinct,  the  chest  is 
often  ill-developed,  pigeon-breasted,  or,  as  pointed  out  by  Lambron,  has 
the  diaphragmatic  constriction  (M.  Mackenzie).  Recurrent  acute  tonsil- 
litis is  generally  complained  of,  but  there  is  seldom  constant  dysphagia  ; 
there  is  an  increase  of  the  pharyngeal  mucus  due  to  catarrh,  and  the  breath 
is  often  foul.  The  actual  dwarfing  and  stunting  from  this  condition  is  some- 
times very  marked.  We  have  seen  a  difference  of  several  months'  growth  in 
twins,  one  of  whom  had  enlarged  tonsils,  the  lost  ground  being  rapidly 
regained  after  removal  of  the  glands. 

It  is  in  our  experience  true  that  enlargement  of  the  tonsils  is  nearly  always 
accompanied  by  the  presence  of  the  closely  allied  adenoid  vegetation  in  the 
naso-pharynx,  to  be  mentioned  presently.  Occasionally,  however,  either 
may  exist  without  the  other.  The  lingual  tonsil  appears  to  be  much  less 
often  affected,  or  at  any  rate  it  very  seldom  gives  rise  to  any  symptoms. 
We  think  it  is  more  common  to  find  adenoid  growths  without  enlargement 
of  the  tonsils  than  hypertrophic  tonsils  without  adenoids. 

Treatment. — Chronic  tonsillar  hypertrophy,  when  once  well  established, 
is  Httle  affected  by  mere  local  apphcations  or  constitutional  treatment  ;  it  is 
only  during  an  attack  of  acute  inflammation  that  good  can  be  done  by  such 
means.  In  the  early  stages  of  the  affection  astringents,  such  as  glycerine  of 
tannin,  and  tonics  sometimes  succeed.  The  only  efficient  mode  of  treat- 
ment is  by  removal  ;  caustics  and  the  actual  cautery  are  inferior  methods  of 
obtaining  the  same  result. 

For  that  form  of  enlargement  in  which  the  tonsils  project  inwards,  or  in- 
wards and  downwards,  nothing  is  so  efficient,  simple,  or  easy  as  removal 
with  the  guillotine.^  Chloroform  should  be  given  if  the  child  will  not  allow 
removal  otherwise ;  there  is  no  objection  to  it  except  that  it  makes  the 
operation  somewhat  more  troublesome. 

As  much  tonsil  as  can  readily  be  removed  should  be  taken  away,  but  it  is 
not  necessary  to  remove  the  whole  gland  ;  the  part  left  behind  usually  soon 
shrinks.  Both  tonsils,  if  enlarged,  should,  if  possible,  be  removed  at  one 
sitting. 

1  Fahnestock's  is  the  one  that  we  prefer,  though  it  is  a  somewhat  delicate  instrument 
and  liable  to  get  out  of  order ;  those  usually  sold  are  too  large  and  clumsy  for  con- 
venient use. 


76  Diseases  of  the  Digestive  System 

The  guillotine  cannot  be  satisfactorily  used  unless  the  tonsils  project  con- 
siderably towards  the  middle  line  ;  in  many  cases,  however,  its  use  may  be 
made  easier  by  pressing  the  tonsil  inwards  with  the  finger  applied  to  the 
neck  just  in  front  of  and  below  the  angle  of  the  jaw.'  Where  the  overgrowth 
is  outwards  and  the  guillotine  cannot  grasp  the  tonsil,  the  vulsellum  and 
guarded  blunt-pointed  bistoury  must  be  used,  care  being  taken  to  keep  the 
edge  of  the  knife  turned  somewhat  inwards.  In  some  few  cases  even  this  is 
impracticable,  and  it  is  only  in  these  rare  instances  that  puncture  with  the 
Paquelin  cautery  should  be  employed  ;  the  cautery  may  be  thrust  through 
the  anterior  pillar  of  the  fauces,  or  directly  into  the  gland  between  the  pillars 
at  one  or  two  points  ;  shrinking  is  said  to  usually  follow.  Potassa  fusa  is 
sometimes  used,  but  is  dangerous  and  tedious  ;  scraping  away  the  tonsils 
with  a  sharp  spoon  is  the  best  plan  if  the  gland  is  very  friable  and  soft. 

Removal  of  enlarged  tonsils  while  acutely  inflamed  is  usually  condemned. 
We  have,  however,  done  it  with  great  relief  to  the  patient  ;  it  is,  of  course, 
very  painful  for  a  few  minutes. 

After  removal  some  swelling  often  follows,  and  may  last  for  a  week  or  so, 
but  then  subsides.  After  free  removal  the  enlargement  rarely  recurs.  We 
have,  however,  seen  two  or  three  instances  where  a  re-growth,  larger  even 
than  the  original  one,  has  appeared  after  a  lapse  of  some  months.  We 
should  be  inclined  to  look  with  suspicion  upon  such  cases  as  possibly  indi- 
cating a  tendency  to  lymphomatous  growth  elsewhere. 

We  have  unintentionally  enucleated  a  tonsil  with  the  guillotine  on 
several  occasions,  the  whole  gland  coming  away  entire  instead  of  being  cut 
through  ;  the  result  was,  of  course,  satisfactory.  It  has  recently  been  pro- 
posed to  revive  this  old  method  of  enucleation,  but  we  think  in  the  majority 
of  cases  it  will  not  be  found  practicable. 

After  the  operation  iced  milk  only  should  be  allowed  for  the  first  day, 
and  milk  and  soft  food  for  the  next  day  or  two  ;  after  this  the  ordinary  diet 
may  be  gradually  resumed.  Painting  the  tonsils  with  glycerine  of  tannin 
after  the  operation  is  perhaps  useful. 

We  have  never  seen  bleeding  follow  the  operation  to  any  serious  extent  ; 
when  it  does  occur  it  usually  arises  from  injury  to  the  pillars  of  the  fauces, 
'  which  are  sometimes  stretched  over  the  tonsil  so  tightly  as  to  be  indistinct. 
A  Httle  ice  to  suck  is  all  that  is  needed  in  most  cases  ;  should  there  be  any 
severe  bleeding,  pressure  or  the  application  of  the  cautery  might  be  re- 
quired.    Injury  to  the  carotid  is,  of  course,  out  of  the  question. 

The  argument  against  the  excision  of  tonsils,  that  the  overgrowth  subsides 
as  the  child  grows  up,  is  altogether  invalid  in  any  severe  case,  for  the  mis- 
chief to  the  general  development,  and  often  to  the  hearing  power,  is  done 
before  the  tonsils  subside.  There  is  no  foundation  for  the  idea  that  any 
wasting  of  the  testes  occurs  from  removal  of  the  tonsils  ;  it  is  much  more  likely 
that  a  lack  of  development  should  be  due  to  the  tonsillar  enlargement  than 
the  reverse.     The  operation  is  an  altogether  harmless  and  beneficial  one. 

Tonsillar  Calculus  is  a  very  rare  condition,  due  to  collection  of  secretion 
or  inflammatory  material  and  subsequent  calcareous  degeneration  ;  the  tonsil 

1  The  tonsil  cannot  be  felt  externally,  but  a  lymphatic  gland  lies  just  on  its  outer  side, 
and  when  enlarged  is  often  mistaken  for  the  tonsil  (Treves). 


Tonsillar  Calculus  yy 

is  enlarged,  hard,  and  often  painful,  the  calcukis  can  befeU  with  a  probe,  and 
should  be  turned  out  of  its  cavity. 

For  the  connection  of  tonsillitis  with  adenitis,  the  reader  is  referred  to  the 
chapter  on  Diseases  of  the  Lymphatic  Glands. 

Enlarg-ed  Vvula. — The  uvula  is  sometimes  acutely  inflamed  as  part  of 
a  pharyngitis  or  is  chronically  enlarged;  in  the  latter  case  it  may  require  to 
be  snipped  oft".     We  have  also  met  with  cases  of  papilloma  of  the  uvula. 

irasal  Adenoid  Growths. — It  often  happens  that  a  child  is  brought  with 
all  the  symptoms  of  tonsillar  hypertrophy — chronic  nasal  catarrh,  pinchedl 
nose,  nasal  obstruction,  snoring,  nasal  voice,  deafness,  stupidity,  &c.  {vide 
Chronic  Tonsillitis),  and  yet  the  tonsils  are  little  if  at  all  enlarged,  or  if 
they  are  their  removal  does  not  cure  the  affection.  In  such  cases  there  is  pro- 
bably overgrowth  of  the  post-nasal  adenoid  tissue,  the  '■pharyngeal  tonsil^  or 
'  Luschkds  tonsil^  so  called.  This  condition,  which  was  first  described  by 
Meyer,  is  very  common  in  childhood  and  is  often  overlooked  ;  it  is,  how- 
ever, readily  found  out  and  treated  if  its  symptoms  are  remembered. 

A  finger  passed  back  into  the  pharynx  and  turned  up  behind  the  soft  palate 
to  the  posterior  nares  will  feel  wart)',  sessile,  or  pedunculated  masses  about 
the  upper  surface  of  the  pharynx  and  round  the  posterior  nares,  often  almost 
completely  blocking  the  apertures.  An  excellent  opportunity  of  seeing  these 
growths  is  afforded  by  cases  of  cleft  palate,  in  which  they  are  nearly  always 
well  marked. 

These  excrescences  bleed  readily,  but  are  not  tender  to  the  touch.  In 
such  cases,  the  vegetations  should  be  scraped  away  with  a  Gottstein's  curette,, 
supplemented  if  necessary  by  the  use  of  a  Volkmann's  spoon  passed  through 
the  nose  and  guided  by  a  finger  in  the  pharynx.  Meyer's  ring  scraper  and 
LoM^enburg's  forceps  are  sometimes  useful,  the  latter  especially  if  the  growths 
are  very  tough.  It  is  far  better  in  these  cases  to  give  chloroform  and  do  the 
operation  thoroughly  than  waste  time  and  trouble  by  incomplete  scrapings 
with  the  finger-nail  or  applications  of  the  cautery  or  other  such  means.  IT 
done  thoroughly  by  the  method  recommended,  it  is  vary  rarely  necessary  to 
repeat  the  operation,  though  occasionally  growths  so  small  as  to  escape 
removal  subsequently  enlarge  and  require  treatment.  It  is  best  to  operate 
with  the  child's  head  thrown  well  back  over  the  end  of  the  table,  so  that  no 
blood  trickles  into  the  air  passages.  This  operation  is  one  that  should  be 
strongly  insisted  upon  ;  it  removes  a  source  of  many  troubles  and  much 
weak  health. 

The  affection  is  an  exceedingly  common  one,  and  may  be  met  with  at  all 
ages.  We  have  seen  it  in  quite  the  first  few  months  of  life,  and  we  believe 
it  is  sometimes  congenital.  No  treatment  except  mechanical  removal  is 
to  be  recommended,  though  the  application  of  caustics  may  in  some  cases 
be  effectual. 

Pharyng'itis  Gangraenosa. — We  have  met  with  two  cases  of  pharyngitis 
in  which  extensive  ulceration  occurred,  and  which  did  not  appear  to  be  due  to 
diphtheria,  scarlet  fever,  or  other  zymotic  disease.  One  of  these  cases  was 
a  hitherto  healthy  boy  aged  nine  years  ;  there  was  little  fever,  but  much  indura- 
tion and  celluhtis  at  the  angle  of  the  jaws.  When  seen  by  one  of  us,  it  was 
impossible  even  under  chloroform  to  get  a  good  view  of  the  fauces  ;  there  were 
one  or  two  smart  haemorrhages  from  the  mouth  presumably  from  ulceration. 


78  Diseases  of  the  Digestive  System 

He  was  apparently  recovering  when  a  sudden  haemorrhage  occurred,  evidently 
from  the  throat,  and  proved  fatal  almost  immediately  ;  no  post-mortem  was 
obtained.  In  the  second  case  there  were  no  haemorrhages,  but  a  deep 
ulceration  of  the  tonsils  and  pharynx ;  the  disease  much  resembled  m  its 
onset  and  course  gangrenous  stomatitis,  and  proved  fatal. 

Post-pharyng-eal  Abscess.— Abscess  in  the  praevertebral  fascia  is 
usually  the  result  either  of  caries  of  the  cervical  spine  (see  Spinal  Disease) 
or  of  suppuration  of  the  lymphatic  glands  in  this  region  from  irritation  about 
the  pharynx  or  posterior  nares.  The  symptoms  are  dysphagia  and  dyspnoea, 
with  pain  and  dribbling  of  saliva  or  mucus  ;  a  peculiar  nasal  or  palatal 
resonance  in  the  cry  is  described  by  Politzer.^  On  examination,  a  soft 
fluctuant  swelling  will  be  felt,  and  the  posterior  wall  of  the  pharynx  will  be 
seen  to  project  unduly,  and  possibly  the  yellowish  colour  of  the  pus  may  be 
seen  through  the  mucous  membrane.  When  the  abscess  is  due  to  simple 
mucous  irritation  it  should  be  opened  through  the  mouth  with  a  guarded 
knife,  the  child  being  turned  on  its  face  as  soon  as  the  incision  is  made,  to 
allow  the  pus  to  flow  dut  readily.  We  have  seen  post-pharyngeal  inflamma- 
tion, without  any  visible  pointing,  give  rise  to  so  much  dyspnoea  as  to  render 
tracheotomy  necessary.  Occasionally  a  large  mucous  cyst,  such  as  that 
described  as  occurring  in  the  tonsil,  is  found  on  the  posterior  wall  of 
the  pharynx  ;  free  incision  is  all  that  is  required  for  these  conditions.  In 
other  instances  suppuration  tracks  round  the  outer  side  of  the  pharynx 
from  the  tonsil  or  soft  palate  or  from  suppurating  cervical  glands  or  other 
neighbouring  parts.  Where  there  is  external  evidence  of  abscess  it  is  better 
to  make  the  opening  in  the  neck,  so  that  the  wound  may  be  rendered 
aseptic,  as  in  abscess  from  spinal  disease.  Other  causes  of  post-pharyngeal 
abscess  are  injuries  and  pharyngitis  ;  it  may  also  occur  in  the  course  of  scarlet 
fever  or  be  the  result  of  a  breaking-down  gumma.  Many  cases  are  recorded 
by  Bokai  as  idiopathic  ;  it  is  not  improbable  that  some  of  these  were 
glandular.  Wiel  gives  otitis  as  a  cause.  Convulsions,  facial  paralysis,  great 
swelling  of  the  neck,  and  spasm  of  the  sterno-mastoid  may  sometimes  occur 
(M.  Mackenzie).  The  disease  has  been  mistaken  for  many  different  affec- 
tions, probably  most  often  for  croup.  Examination  of  the  throat  by  the  eye 
and  finger  will  always  clear  up  a  doubt  in  the  later  stages,  though,  as  already 
pointed  out,  the  diagnosis  may  be  very  obscure  at  first. 

We  have  met  with  these  abscesses  in  quite  young  infants  as  well  as  in 
older  children.  In  a  case  that  we  saw  a  finger  passed  into  the  abscess  cavity 
could  find  its  way  between  the  vertebrae  and  the  pharynx  upwards  nearly  to 
the  base  of  the  skull,  and  downwards  almost  to  the  root  of  the  neck.  The 
abscess  was  probably  the  result  of  suppuration  in  a  retro-pharyngeal  lymphatic 
gland,  and  caused  both  dysphagia  and  dyspnoea. 

Retro-oesophageal abscess  sometimes  occurs,  and  may  give  rise  to  dyspnoea 
necessitating  tracheotomy,  rarely  to  dysphagia  ;  it  may  be  due  to  spinal 
caries  or  extension  of  suppuration  from  other  parts.-  It  is  not  so  common  in 
children  as  the  retro-pharyngeal  abscess.  When  it  occurs  there  is  swelling 
on  both  sides  of  the  neck,  dryness  of  the  throat,  tenderness  and  pain  on 
movement,  with  fever  and  alteration  of  the  voice.  The  abscess  may  burst 
1  Jahrbuch  f.  Kinderheilk.  B.  xxi.  H.  i,  2. 
-  Ripley,  Archiv.  of  Pesdiatrics,  Feb.  1884. 


Post-pharyngeal  Abscess  yg 

into  the  oesophayus  or  Ijurrow  round  the  neck.  W'e  have  recently  met  with 
three  cases  of  abscess  bursting  into  the  ccsophagus  :  in  two  caries  of  the  spine, 
and  in  the  other  tuberculous  gland  disease  was  the  cause  of  the  abscess. 
According  to  Barthez  and  Rilliet,  a  form  of  dry  coryza,  with  even  coma  or 
convulsions,  may  occur,  and  the  onset  may  be  sudden.  After  the  abscess 
has  burst,  '  traction  diverticula,'  or  stricture  of  the  gullet,  may  result.  The 
prognosis  is  bad.  Fomentations  and  feeding  by  enemata  or  an  oesophageal 
tube  should  be  the  early  treatment,  with  incision  at  the  posterior  border  of 
the  sterno-mastoid  as  soon  as  there  is  distinct  evidence  of  suppuration. 

Stricture  of  CEsopbag'us. — Apart  from  congenital  malformations, 
oesophageal  obstruction  in  children  is  due  either  to  paralysis,  or  to  cicatricial 
strictures,  resulting  usually  from  swallowing  hot  or  corrosive  liquids,  such  as 
potash,  hydrochloric  acid,  &c.  In  such  cases  there  is  immediate  dang-er  of 
suffocation  from  implication  of  the  larynx,  as  well  as  more  or  less  dysphagia 
from  pain  and  swelling.  These  troubles,  howevei,  may  be  slight  and  tran- 
sient, and  yet  after  a  time  cicatricial  stricture  may  appear,  or  the  obstruction 
may  be  present  from  the  first. 

In  cicatricial  strictures  there  is  a  good  deal  of  muscular  spasm  present, 
either  constantly  or  from  time  to  time,  and  this  may  be  much  increased  by  the 
passage  of  bougies.  In  some  cases  it  is  impossible  to  pass  even  a  small  in- 
strument without  an  anaesthetic,  and  yet  a  fair-sized  one  maybe  admitted  when 
the  child  is  fully  under  chloroform.  Sometimes  at  intervals  the  child  is  able 
to  swallow  fairly  freely,  while  at  other  times  the  obstruction  is  almost  com- 
plete. The  profuse  secretion  of  saliva  and  mucus  is  often  very  distressing. 
Such  contractions  are  most  commonly  situated  high  up  in  the  gullet,  but  they 
may  be  very  extensive.  The  position  of  the  stricture  may  be  ascertained  by 
auscultation  during  drinking,  or  by  the  passage  of  bougies,'  after  the  history 
of  the  accident  and  the  dysphagia  have  led  to  the  discovery  of  the  obstruc- 
tion. A  careful  examination  should  be  made  of  the  oesophagus,  to  find  out 
if  possible  the  calibre,  position,  and  number  of  the  strictures,  but  bougies 
must  be  used  with  the  utmost  gentleness.  We  have  had  a  case  of  perforation 
of  the  oesophagus  and  escape  of  fluid  into  the  pleura  in  our  own  experience. 
In  a  case  which  we  saw  with  Mr.  T.  H.  Pinder  he  told  us  that  at  one  time 
marked  improvement  in  power  of  swallowing  followed  entire  deprivation  of 
all  food  by  mouth  ;  the  child  was  supported  for  some  days  entirely  by 
enemata,  and  it  is  probable  that  absence  of  irritation  caused  relaxation  of 
muscular  spasm,  though  there  was  a  possibility  that  the  relief  was  due  to  a 
sloughing  off  of  the  edge  of  the  constricting  cicatrix  at  least  in  part,  or  it 
may  have  been  merely  that  there  was  an  interval  in  the  progress  of  the  con- 
traction analogous  to  that  occurring  in  cases  of  malignant  disease.  Mr.  Pinder 
suggested  that  abstinence  might  also  have  diminished  the  size  of  the  pouch 
which  forms  in  these  cases  above  the  stricture,  and  so  abolished  the  valve- 
like obstruction  to  some  extent. 

The  best  treatment  of  oesophageal  stricture  in  such  cases  is  usually  that 
by  gradual  dilatation  with  bougies.-'     The  drawback  to   it  is  that  relapse   is 

'  In  new-Vjorn  children  the  distance  from  the  gums  to  the  cardiac  orifice  is  about  seven 
inches  (Sir  Morell  Mackenzie). 

-  Keller  records  thirty-five  cases  under  two  years  of  age  with  twenty-three  cures,  im- 
provement in  three  cases,  and  five  deaths,  four  remaining  under  treatment. 


8o  Diseases  of  the  Digestive  System 

very  apt  to  occur  as  soon  as  the  daily  passage  of  the  instrument  is  omitted. 
Forcible  dilatation  by  MacCormac's  dilator  and  internal  oesophagotomy  have 
been  employed  ;  the  former  may  be  useful,  the  latter  is  too  dangerous.  Fail- 
ing these,  oesophagostomy  may  be  performed  if  the  stricture  is  limited  to  the 
upper  part  of  the  gullet,  or  if  not,  gastrostomy  ;  the  latter  operation  is  the 
safer  and  the  more  generally  applicable  one.  If  an  operation  is  to  be  done, 
it  must  not  be  put  off  too  long.  As  soon  as  it  is  clear  that  dilatation  is  insuf- 
ficient and  the  child  is  losing  weight,  no  further  time  should  be  wasted. 
Done  early,  and  done  in  two  stages  (Howse),  some  success  maybe  expected 
from  gastrostomy,  and  the  rest  given  to  the  gullet  by  the  operation  may 
result  in  restoration  of  the  canal  subsequently  (Davies  Colley),  or  it  may  be 
possible  to  dilate  or  divide  the  stricture  by  instruments  passed  upwards 
from  the  stomach  into  the  oesophagus.  For  details  of  the  operations  we 
must  refer  to  the  general  text-books.  In  a  case  in  which  we  performed 
gastrostomy  there  was  much  trouble  from  regurgitation  of  the  food  through 
the  gastric  fistula.  The  wound  became  unhealthy,  and  the  child  died  of 
abscess  between  the  liver  and  stomach. 

Oesophageal  stricture  from  congenital  syphilis,  and  obstruction  from 
pressure  of  abscesses  outside  the  gullet  or  from  traction  by  cicatricial  tissue 
around  (perioesophageal  abscess),  are  occasionally  met  with,  as  in  the  follow- 
ing case,  in  which  stricture  of  the  oesophagus  followed  scarlet  fever  : 

Hannah  N.,  oet.  three,  had  scarlet  fever  six  months  before  admission.  The  attack 
was  a  severe  one,  with  a  bad  throat  and  suppuration  of  cervical  glands.  She  was  admitted 
April  4,  1892,  with  stricture  of  the  oesophagus,  severe  enough  to  have  prevented  swallowing 
sohds  for  some  time  past.  Takes  milk  and  gruel.  The  obstruction  was  at  the  level  of  the 
cricoid,  and  even  the  smallest  bougie  could  not  be  passed  through  it.  The  pharynx  above 
the  stricture  was  dilated,  causing  a  protrusion  on  the  left  side  of  the  neck.  She  was  able 
to  swallow  milk  and  fine  sop,  and  gained  weight  in  hospital.  She  was  taken  out,  and 
again  admitted  in  the  following  October,  when  the  symptoms,  which  had  abated, 
became  worse  upon  attempting  to  swallow  some  apple.  There  was  then  complete 
obstruction,  but  under  chloroform  a  small  catheter  (No.  3,  English)  was  passed  through 
the  stricture,  which  apparently  extended  for  a  considerable  distance.  When  heard  of  two 
years  afterwards,  she  could  eat  bread  and  butter  and  mashed  potatoes  very  well,  but  could 
not  swallow  meat.     She  was  well  nourished. 

Swallowing'  Foreig-n  Bodies. — It  is  very  common  for  children  to  be 
brought  with  a  history  of  having  swallowed  a  farthing  or  button,  or  some- 
thing of  the  kind,  and  much  alarm  is  caused  to  the  child  and  its  friends. 
In  many  cases  the  history  is  a  mistaken  one,  in  others  the  foreign  body 
passes  into  the  stomach,  gives  rise  to  no  symptoms,  and  is  voided  in  a  day 
or  two  with  the  motions. 

The  only  treatment  required  in  such  cases  is  to  give  the  child  plenty  of 
bread,  potatoes,  suet  pudding,  &c.,  to  provide  a  sufficient  faecal  sheathing  for 
the  harmless  passage  of  the  body. 

In  some  few  instances,  however,  an  angular  mass  such  as  a  bone,  or  a 
sharp-pointed  object  such  as  a  pin,  may  be  swallowed,  and  may  be  arrested  in 
the  pharynx  or  oesophagus.  In  such  cases  there  is  usually  some  obvious  sign 
of  its  presence,  such  as  pain,  dysphagia,  retching  or  vomiting  ;  possibly  some 
blood-stained  mucus  is  Isrought  up.  Within  the  last  year  or  so  we  have  had 
four  cases  under  our  care  in  which  a  halfpenny  has  been  swallowed,  and 


SivalUnving  Foreign  Bodies  ,  8 1 

in  each  case  it  was  clearly  shown  by  a  radiogram  just  behind  the  top 
of  the  sternum  with  the  faces  of  the  coin  antcro-posterior.  In  one  instance 
the  coin  had  been  six  weeks  in  the  gullet,  and  in  none  of  the  cases  were 
there  any  very  severe  symptoms.  In  each  instance  we  removed  the 
halfpenny  by  means  of  the  '  coin  catcher,'  while  the  child  was  under  an 
aniusthetic  ;  no  trouble  followed  in  any  of  them. 

If  there  is  no  urgent  dyspnoea,  a  careful  examination  of  the  fauces  should 
first  be  made,  to  see  if  the  object  is  not  lodged  between  the  pillars  ;  failing 
this,  the  finger  should  be  passed  to  the  back  of  the  throat,  and  the  root  of 
the  tongue  and  epiglottis  be  searched,  care  being  taken  not  to  mistake  the 
cornua  of  the  hyoid  for  a  foreign  body.  If  nothing  is  found,  and  the  site  of 
the  body  can  be  felt  from  the  outside  of  the  neck,  and  especially  if  the  mass 
is  hard,  angular,  and  insoluble,  an  attempt  should  be  made  to  remove  it 
with  the  bristle  probang  or  coin  catcher,  or  faiHng  these,  possibly  with 
oesophageal  forceps,  though  these  are  more  dangerous.  Failing  these  plans, 
the  choice  lies  between  an  attempt  to  push  the  foreign  body  on  into  the  stomach 
and  the  performance  of  oesophagotomy.  The  first  plan  should  be  followed  in 
the  majority  of  cases,  and  can  be  best  managed  by  the  gentle,  steady  use 
of  a  good-sized  bougie.  It  is  applicable  to  instances  where  the  foreign  body 
is  soft,  smooth,  and  rounded,  and  not  likely  to  give  rise  to  trouble  in  its 
passage  through  the  intestines.  It  must  be  remembered  that  a  feeling  of 
soreness  and  irritation  may  remain  about  the  fauces  for  some  time  after  the 
passage  and  removal  of  a  foreign  body,  and  may  give  rise  to  the  belief  that 
there  is  still  something  there.  In  cases  of  swallowing  fish  bones,  and  their 
becoming  impacted,  doses  of  hydrochloric  acid  or  vinegar  and  water  may  be 
given,  but  the  remedy  is  unpleasant  and  tedious.  An  aneesthetic  may  be 
used  to  lessen  the  discomfort  of  examination.  Emetics,  as  a  rule,  are  not 
good  treatment.  As  in  the  cases  mentioned,  skiagrams  are  of  the  greatest 
value  in  many  of  these  cases. 

(Esopbagritls — Infantile  oesophagitis,  first  described  by  Billard,  is  a  rare 
disease,  supposed  to  be  caused  by  irritation  from  bad  milk,  improper  feeding, 
or  sore  nipples.  The  symptoms  are  unwillingness  to  suck,  crying  and  im- 
mediate regurgitation  after  beginning  to  suck,  and  often  some  tenderness 
about  the  neck  on  pressure.  The  inflammation  may  be  local  or  general,  and 
.  may  give  rise  to  ulcers  or  sloughing,  and  possibly  to  subsequent  stricture. 
The  prognosis  is  bad  ;  the  disease  may  come  on  immediately  after,  or  even 
exist  at  birth.  It  is  not  likely  to  be  mistaken  for  anything  except  congenital 
malformation,  in  which  the  obstruction  is  absolute.  Cleanliness,  careful 
feeding,  and  the  administration  of  glycerine  of  borax  in  small  doses,  con- 
stitute the  treatment.' 

Other  rare  conditions  met  with  are  congenital  hypertrophy  of  the  mucous 
glands  and  varix  of  the  oesophagus. 

I  Sir  Morell  Mackenzie. 


82  Diseases  of  the  Digestive  System 


CHAPTER  V 

DISEASES    OF   THE   DIGESTIVE    SYSTEM    {continued) 

Examination  oi  the  Abdomen. — Inspection. — The  abdomen  in  infancy 
is  proportionately  larger  and  more  rounded  in  appearance  than  the  abdomen 
of  adults,  and  this  is  at  once  apparent  on  inspection  as  the  infant  lies  stripped 
in  its  cot  or  on  its  mother's  lap.  An  exaggeration  of  this  condition  is  often 
seen  in  cases  of  chronic  dyspepsia  or  intestinal  catarrh  ;  there  is  great 
distension  of  the  intestines  with  'bound  wind,'  the  abdomen  being  much 
increased  in  girth  and  the  skin  stretched  and  shiny.  If,  as  is  often  the  case, 
there  is  more  or  less  wasting  of  the  fatty  tissues,  the  large  abdomen  con- 
trasts strangely  with  the  wasted  and  shrivelled  form  of  the  infant,  giving  it  a 
very  characteristic  appearance.  The  large  liver  of  the  infant  is  responsible 
to  some  extent  for  the  disproportionate  size  of  the  abdomen.  An  inspection 
of  the  abdomen  will  reveal  any  enlarged  veins  on  the  surface,  or  the 
presence  of  large  tumours  or  an  excessive  amount  of  fluid  in  the  peritoneum. 
The  umbilicus  will  be  examined  at  the  same  time,  and  any  hernia  or  local 
lesion  here  detected.  Instead  of  a  distended  abdomen,  the  condition  of 
flatness  or  retraction  may  be  present,  especially  if  there  is  acute  cerebral 
disease. 

Palpation. — The  muscular  wall  of  the  abdomen  is  comparatively  thin, 
and  less  rigid  in  infants  and  young  children  than  it  is  in  adults,  and  con- 
sequently palpation  yields  more  definite  results,  and  is  therefore  of 
greater  value  as  a  means  of  diagnosis.  Thus  in  young  children  the  edge  of 
the  liver,  an  enlarged  spleen  or  kidney,  fa;ces  in  the  colon,  a  distended 
bladder,  a  matted  and  thickened  omentum,  and  much  enlarged  mesenteric 
glands  may  be  felt  by  more  or  less  deep  pressure  by  the  hand  on  the 
abdomen.  It  is  needless  to  say  that  the  conditions  are  not  always 
favourable  ;  distension  of  the  intestines  with  gases  so  as  to  bulge  and  distend 
the  abdominal  walls  will  necessarily  interfere  with  palpation  of  the  abdomen; 
then,  again,  a  fractious  and  crying  child  is  necessarily  difficult  to  examine  in 
this  way.  But  even  under  the  most  unfavourable  circumstances,  the  warm 
hand,  laid  on  the  abdomen  and  firmly  pressed  in,  may  detect  a  tumour  or 
some  enlarged  organ,  and  information  be  gained  which  may  be  of  great 
advantage  in  making  a  diagnosis.  Even  ascertaining  the  tenseness  or  laxity 
of  the  abdominal  walls  is  of  importance  in  forming  a  diagnosis  between 
cerebral  and  gastric  vomiting,  as  in  cerebral  disease  there  is  mostly  a  relaxed 
state  of  the  walls  of  the  abdomen  which  enables  the  edge  of  the  liver  and 
perhaps  other  organs  to  be  felt  with  abnormal  distinctness  ;  while,  on  the 


Examination  of  the  Abdomen  83 

other  hand,  in  gastro-intestinal  disorders  there  is  usually  more  or  less  disten- 
sion of  the  stomach  and  bowels,  the  distended  organs  interfering  with  a 
thorough  exploration  of  the  abdominal  contents.  Palpation  may  give 
valuable  information  with  regard  to  pain  and  tenderness  in  the  abdomen, 
provided  the  observer  is  alive  to  the  fallacies  which  may  arise  through  the 
fractiousness  of  his  little  patient. 

We  note  here  that  palpation  with  the  forefinger  in  the  rectum  may  give 
valuable  information  in  some  conditions,  as  in  invagination  of  the  bowel, 
tumour,  abscess,  &c.,  in  the  abdomen. 

V>y  percussion  the  investigator  is  able  to  confirm  the  results  obtained  by 
palpation,  and  gain  information  not  otherwise  obtainable  ;  thus  he  may  map 
out  by  percussion  the  outline  of  a  dilated  stomach,  or  ascertain  the  limits  of 
fluid  in  the  peritoneum. 

Anatomically  the  abdomen  of  the  infant  differs  from  the  adult's  in  that 
the  liver  is  proportionately  larger  in  the  newly  born  infant,  occupying  at 
least  half  of  the  abdominal  cavity.  The  inferior  limit  of  the  liver  is  con- 
sequently lower,  and  the  left  lobe  covers  the  stomach  to  a  greater  extent  in 
the  infant  than  in  the  adult.  The  infant's  stomach,  so  far  as  shape  is  con- 
cerned, does  not  differ  in  any  important  respect  from  the  adult's  ;  the  cardiac 
curvature  is  perhaps  less  well  marked,  and  it  comes  into  closer  relation  with 
the  liver  and  spleen.  As  a  consequence  of  the  thinness  of  their  walls,  the 
stomach  and  intestines  are  apt  to  become  dilated  during  infancy  from  the 
pressure  of  gases  given  off  from  their  contents,  and  to  remain  more  or  less 
constantly  in  a  distended  state.  The  large  intestines — more  especially  the 
ctBCum,  ascending  colon,  and  sigmoid  flexure — are  more  movable,  and  con- 
sequently more  easily  dragged  from  their  normal  position,  in  infants  than 
in  adults.  This  is  especially  true  of  the  sigmoid  flexure,  for  sometimes  at 
an  autopsy  the  sigmoid  flexure,  if  distended  with  gas  or  faeces,  may  be  found 
much  displaced  towards  the  right  side.  This  must  be  remembered  in  pal- 
pating the  abdomen,  for  faeces  which  from  their  position  may  appear  to  be 
in  the  ileum  or  Ccccum  may  in  reality  be  in  a  displaced  sigmoid  flexure. 

The  Dyspeptic  Diseases  of  Infancy  and  Childliood. —  No  infant, 
whether  fed  at  the  breast  or  with  artificial  foods,  escapes  having  indigestion 
in  one  form  or  another  ;  it  is  certain  that  sooner  or  later  various  dyspeptic 
ailments  will  supervene  and  form  no  insignificant  part  of  the  troubles  of  an 
infant's  life.  We  have  not  far  to  go  to  seek  an  explanation  of  this.  The 
alimentary  canal  of  an  infant  is  exceedingly  intolerant  of  any  form  of  irrita- 
tion, while,  with  very  slender  resources  to  fall  back  upon,  it  has  to  perform  a 
large  amount  of  work  in  the  digestion  of  food  in  order  to  make  good  the 
losses  incident  to  life  and  supply  suitable  material  for  the  rapid  growth  which 
is  taking  place.  During-  the  whole  of  infancy  the  digestive  apparatus  is 
worked  to  its  uttermost  capacity  in  digesting  the  food  required  for  the  infant's 
maintenance  and  growth,  and  any  overtaxing  of  its  powers  is  very  likely  to 
be  followed  by  disturbed  function.  The  commonest  causes  of  indigestion 
in  infancy  are  practically  the  same  as  those  in  adults  :  the  appetite  perhaps 
is  in  excess  of  the  digestive  powers,  and  more  food  is  taken  than  can  be 
digested,  or  the  food  taken  is  of  an  improper  quality  ;  in  both  rases  the 
result  is  the  same,  the  digestive  juices  are  weakened,  the  food  decomposes 
in  the  alimentary   canal,  toxic  products  are  formed,  and  vomiting,  colic,  or 

G   2 


84  Diseases  of  the  Digestive  System 

diarrhoea  occurs.  In  some  cases  the  vomiting  points  to  the  stomach  being 
most  affected  ;  in  others  the  passage  of  loose  stools  containing  undigested 
food,  with  much  flatulence,  indicates  that  the  small  intestines  are  involved, 
the  large  bowel  when  colic,  tenesmus,  and  an  excoriated  condition  of  anus 
are  present.  In  the  mild  cases  there  is  a  deficient  secretion  or  impaired 
quality  of  the  digestive  juices  so  that  they  are  incompetent  to  digest  the 
amount  of  food  taken,  decomposition  products  are  formed,  which  give  rise 
to  discomfort,  until  expelled  by  vomiting  or  diarrhoea.  In  the  severe  or 
more  prolonged  forms  there  is  a  catarrhal  condition  of  the  mucous  membrane 
which  is  more  or  less  obstinate  in  its  course.  In  discussing  these  dyspeptic 
conditions  arising  during  infancy  and  childhood,  it  is  convenient  to  consider 
the  prominent  symptoms  separately,  always  bearing  in  mind,  however,  that 
they  are  only  symptoms  of  morbid  conditions  and  not  diseases. 

Flatulence  and  colic  may  be  present  unaccompanied  by  either  vomit- 
ing or  diarrhoea,  both  breast-fed  and  bottle-fed  babies  alike  suffering,  though 
the  latter  do  so  more  frequently.  It  is  the  result  in  many  instances,  perhaps 
niost  frequently,  of  the  infant  taking  its  food  too  quickly  and  in  too  large 
quantities  ;  digestion  is  performed  imperfectly,  fermentation  takes  place  in  the 
small  intestines,  and  gases  are  formed  which  distend  the  bowels.  The 
abdomen  is  distended,  the  infant  is  restless  and  cannot  sleep,  it  is  constantly 
crying  and  tossing  about,  and  if  it  brings  up  or  passes  large  quantities  of 
flatus,  there  is  much  relief  Ease  for  the  most  urgent  symptoms  may  be 
found  in  giving  the  infant  a  teaspoonful  or  two  of  an  equal  quantity  of  lime 
water  and  cinnamon  water,  or  small  doses  of  carbonate  of  ammonia  and  soda 
in  peppermint  water,  or  a  small  piece  of  the  compressed  salts  known  as 
'  soda-mints,'  dissolved  in  a  little  syrup.  It  will  be  necessary,  temporarily  at 
least,  to  lessen  the  amount  of  food  which  the  infant  is  taking  ;  this  can  be 
done  in  breast-fed  children  by  givmg  them  some  sweetened  barley  water  or 
whey  before  taking  the  breast,  and  not  allowing  the  breast  to  be  given  for  too 
long  or  too  often.  In  artificially  fed  infants  the  amount  of  food,  especially 
the  amount  of  curd,  must  be  reduced  either  by  dilution  with  barley  water, 
lime  water,  or  by  predigesting  the  curd.  Large  enemata  of  warm  water 
(10-15  02-)  ^^d  hot  fomentations  to  the  abdomen  will  generally  relieve  the 
severer  cases  of  colic  due  to  flatulence,  and  a  grain  of  mercury  and  chalk 
powder  combined  with  half  a  grain  of  Dover's  powder  may  be  given  by  the 
mouth.  Carbonate  of  magnesia  with  syrup  of  ginger  is  often  useful.  (F.  11,14.) 

Vomiting'. — Vomiting  is  a  very  common  complaint  during  infancy,  and 
babies  that  vomit  are  among  the  most  troublesome  cases  with  which  we 
have  to  deal.  There  is  a  hypersensitive  condition  of  the  mucous  membrane 
of  the  stomach,  excessive  peristaltic  movements  take  place,  and  the  stomach 
contents  are  vomited  with  more  or  less  force.  In  some  of  the  minor  cases 
vomiting  is  due  to  overfeeding,  or  the  food  is  too  rich  in  fat  or  proteid  ;  in 
more  serious  cases  there  is  mostly  a  gastric  catarrh,  which  is  difficult  to  get 
rid  of  The  most  frequent  way  in  which  food  is  rejected  from  the  stomach 
is  by  what  is  termed  by  mothers  '  posseting,'  which  consists  of  eructations  of 
small  quantities  of  fluid  from  time  to  time  without  any  effort,  the  food 
escaping  from  the  corners  of  the  infant's  mouth  in  consequence  of  a  too 
vigorous  peristaltic  action  of  the  stomach.  Fluid  will  also  frequently 
regurgitate  during  the  eructation  of  gases  from  the  stomach.     In  true  vomit- 


Vomiting  85 

ing  there  is  more  or  less  retching,  and  the  contents  of  the  stomach  come  up 
with  considerable  force.  Vomiting  is  especially  common  in  infants  who  are 
taking  cow's  milk,  and  who  are  unable  to  digest  the  large  quantities  of  hard 
curd  contained  in  the  milk,  the  stomach  probably  containing  much  decom- 
posing curd  and  mucus.  The  stomach  is  perhaps  dilated  and  toneless,  does 
not  completely  empty  itself,  while  its  contents  consist  of  decomposition 
products.  Any  milk  food  on  entering  the  stomach  quickly  undergoes 
fermentation.  Sometimes  the  vomiting  is  the  result  of  over-distension,  or 
the  formation  of  excessive  quantities  of  gases,  or  of  coughing.  The  vomiting 
of  breast-fed  infants  is  often  due  to  their  being  given  the  breast  at  too 
frequent  intervals,  or  to  some  other  cause,  as  the  ingestion  of  unsuitable 
food  on  the  part  of  the  mother  ;  or  she  may  be  suffering  some  great  anxiety, 
which  is  in  itself  quite  sufficient  to  cause  an  alteration  in  the  quality  of  the 
breast  milk.  Vomiting  in  infants  a  few  days  old  may  be  the  result  of  some 
congenital  obstruction  at  the  pylorus.  It  must  also  be  borne  in  mind  that 
vomiting  in  infants  and  children  is  frequently  reflex,  and  not  due  to  any 
lesion  of  the  stomach,  but  the  result  of  cerebral  disease,  as  meningitis,  or 
tumour,  or  of  the  irritation  caused  by  cutting  a  tooth.  Vomiting  is  some- 
times the  first,  and  for  a  time  the  only,  symptom  in  tubercular  meningitis, 
and  may  precede  for  a  week,  or  even  longer,  any  marked  cerebral  symptoms. 
Reflex  vomiting  may  at  first  be  entirely  undistinguishable  from  dyspeptic 
vomiting  ;  the  condition  of  the  tongue  is  no  certain  guide,  and  it  is  only  as 
the  cerebral  symptoms  become  more  marked,  the  abdominal  walls  either 
retracted  or  in  a  toneless,  flabby  condition,  that  a  diagnosis  can  be  made. 
In  older  children  the  vomiting  of  an  acute  gastric  catarrh  may  last  for  a  few 
days,  but  any  long-continued  or  habitual  vomiting  is  very  suspicious  of 
cerebral  disease.  The  vomiting  of  a  cerebral  tumour  is  very  erratic,  comes 
and  goes  suddenly,  there  is  usually  headache  and  optic  neuritis.  Hj^sterical 
vomiting  is  occasionally  seen  in  girls  about  puberty.  Vomiting  is  usually  an 
early  symptom  of  scarlet  fever  and  also  of  influenza. 

The  treatment  of  vomiting  must  necessarily  depend  upon  its  cause. 
Vomiting  in  the  breast-fed  infant,  provided  the  mother's  manner  of  life  or 
diet  is  not  at  fault,  is  probably  the  result  of  too  large  quantities  of  milk  being 
taken  or  it  is  too  rich  ;  it  will  generally  be  sufficient  to  insist  upon  regular 
hours  of  feeding  at  not  too  frequent  intervals,  and  to  give  the  infant  a  i&w 
teaspoonfuls  of  sweetened  lime  water  before  it  has  the  breast,  with  a  dose  or 
two  of  hyd.  c.  creta  to  act  on  the  bowels.  If  this  is  not  successful  give  the 
infant  some  whey  or  barley  water  for  a  few  meals,  while  the  mother's  breasts 
are  drawn  by  means  of  a  pump.  Do  not  be  in  too  great  a  hurry  to  wean. 
Vomiting  in  the  bottle-fed  infant  is  more  difficult  to  deal  with,  especially 
when  a  gastric  catarrh  exists.  The  infant  is  under  these  circumstances  very 
intolerant  of  cow's  milk,  even  when  largely  diluted,  the  milk  being  quickly 
curdled  in  the  stomach,  and  the  hard  lumps  of  curd  are  vomited  in  masses. 
In  the  milder  cases  it  may  probably  be  sufficient  to  resort  to  dilution  of  the 
milk,  thus  decreasing  its  richness,  or  to  feed  the  infant  entirely  on  whey 
or  barley  water  for  twenty-four  or  forty-eight  hours.  Sterilised  milk, 
condensed  milk,  or  desiccated  milk  is  nearly  always  retained  more  readily 
than  fresh  cow's  milk  by  infants  who  vomit.  Whatever  food  is  resorted  to, 
g'reat  care  must  be  taken  that  too  large  quantities  are  not  given  at  a  time  or 


86  Diseases  of  the  Digestive  System 

taken  too  quickly.  In  severer  cases,  where  no  form  of  fresh  milk  is  tolerated, 
milk  peptonised  by  the  addition  of  Benger's  peptonising  powders,  or  the 
condensed  peptonised  milk  sent  out  in  tins  is  frequently  useful.  If  the 
vomiting  is  severe  and  continued,  the  bottle  must  be  done  away  with  and 
the  infant  fed  by  the  spoon  or  pipette,  or  a  wet  nurse  may  be  obtained.  An 
alkali,  such  as  carbonate  of  soda,  with  two  or  three  grains  of  pepsine  in 
powder,  may  be  given  before  meals  ;  or  bismuth  and  nux  vomica  may  be 
tried.  Washing"  out  the  infant's  stomach  is  often  extremely  useful,  the 
infant  ceasing  to  vomit  after  the  acid  mucus  and  decomposing  curd  have 
been  removed.     (F.  15,  F.  16.) 

Diarrlicea. — Looseness  of  the  bowels  is  symptomatic  of  many  different 
disorders  and  morbid  conditions.  An  attack  of  diarrhoea  frequently  ushers  in 
scarlet  fever,  or  may  be  present  in  all  stages  of  the  malignant  form  ;  it  may 
accompany  typhoid  fever  ;  it  is  often  present  in  septicaemia,  empyema, 
uraemia,  peritonitis.  The  commonest  form  in  children  is  the  result  of 
an  accumulation  of  undigested  food  in  the  intestines,  or  of  some  irritating 
matters  taken  in  the  food.  Infants  at  the  breast  are  liable  to  suffer  from 
looseness  of  the  bowels  soon  after  birth  on  account  of  the  colostrum  not 
agreeing  with  them  ;  they  are  also  liable  to  suffer  from  the  taking  of  im- 
proper food  on  the  part  of  the  mother  during  lactation  ;  over-feeding  or  a 
fit  of  anger,  or  other  strong  emotion  on  the  part  of  the  mother,  has  been 
known  to  be  followed  by  diarrhcea  in  the  infant.  Artificially  fed  infants 
are  much  more  liable  to  suffer  than  infants  at  the  breast.  The  difficulty 
with  which  the  curd  of  cow's  milk  is  digested  overtaxes  the  digestive 
powers,  the  undigested  curd  irritates  the  bowels,  and  increased  peristalsis 
is  set  up.  An  intestinal  catarrh  is  soon  established,  the  infant  is  restless, 
peevish,  and  cannot  be  got  off  to  sleep,  the  abdomen  is  distended  with  gas, 
the  legs  are  drawn  up,  and  the  infant  passes  perhaps  five  or  six  stools  or 
more  per  diem.     A  severe  chill  may  give  rise  to  colic  and  diarrhoea. 

An  examination  of  the  napkin  shows,  instead  of  the  bright  yellow  homo- 
geneous stools  of  the  healthy  infant,  green  and  curdy  motions,  or  one 
consisting  of  a  yellowish  or  green  slimy  fluid.  The  infant  is  thirsty,  takes  the 
breast  or  the  bottle  vigorously  at  first,  but  is  soon  satisfied  and  pushes  it 
away  when  offered.  The  tongue  is  coated  and  the  mouth  is  often  the  seat 
of  aphthous  stomatitis.  Vomiting  may  be  present,  but  is  mostly  absent.  In 
a  day  or  two  the  infant  begins  to  waste,  the  muscles  of  the  limbs  grow  flabby, 
and  the  skin  hangs  about  the  thighs  in  loose  folds,  and  the  parts  about  the 
anus  and  genitals  become  red  and  frequently  raw.  Some  infants  are  liable 
to  such  attacks  especially  during  hot  weather,  and  the  final  result  may  ,be  a 
more  or  less  chronic  condition  of  catarrh,  to  end  finally  in  general  malnutri- 
tion from  gastro-intestinal  atrophy.  Rickets  is  a  very  frequent  sequence  of 
intestinal  catarrh. 

Not  infrequently  the  symptoms  point  to  a  catarrh  of  the  large  bowel,  and 
are  more  of  a  dysenteric  character.  Dysenteric  diarrhoea  may  be  primary, 
or  follow  an  attack  of  simple  diarrhoea,  the  general  affection  passing  away 
and  leaving  a  local  inflammatory  condition  in  the  colon,  sigmoid  flexure,  and 
rectum.  The  same  form  of  diarrhoea  frequently  succeeds  whooping  cough 
and  measles.  There  is  distension  of  the  abdomen,  with  often  more  or  less 
tenderness  in  the  left  iliac  region  on  pressure,  frequent  passage  of  small 


Diarr/uea  Sy 

liquid  stools,  consisting  largely  of  mucus,  biliary  matters,  and  perhaps  blood, 
preceded  by  much  straining  and  forcing  down  and  frequently  followed  by 
prolapse  of  the  rectum.  Older  children  often  suffer  from  this  form  of  catarrh 
of  the  large  bowel,  passing  lumpy  mucoid  stools,  and  getting  up  perhaps 
several  times  in  the  night  to  sit  on  the  vessel,  only  passing  each  time  a  little 
mucus  streaked  with  blood.  Dysenteric  diarrhoea  is  apt  to  become  chronic, 
alternately  better  and  worse,  until  the  patient  is  reduced  to  a  condition  of 
wasting.  Sometimes  dysenteric  diarrhoea  occurs  in  epidemics  in  winter  as 
well  as  in  summer.     We  have  known  several  such  epidemics. 

Older  children  sometimes  habitually  suffer  from  what  has  been  termed 
'  lienteric '  diarrhoea,  in  which  a  loose  stool  is  apt  to  follow  the  ingestion  of 
food.  Such  children  are  generally  subject  to  loose  bowels,  a  diarrhoeal  stool 
following  any  form  of  excitement,  especially  a  fright,  the  immediate  cause 
being  an  exaggerated  peristaltic  action  of  the  ileum  and  colon.  There  is 
often  in  such  cases  a  catarrh  of  the  large  bowel,  as  evidenced  by  the  excess 
of  mucus  which  is  passed  :  phthisical  children  also  may  suffer  in  this  way.  A 
form  of  diarrhoea  which  has  been  termed  '  fat  diarrhoea,'  from  the  presence 
of  an  excessive  quantity  of  fat  in  the  stools,  has  been  described  ;  it  is 
presumably  due  to  catarrh  of  the  duodenum  and  pancreatic  duct. 

In  the  sHghter  forms  of  diarrhoea  in  infants,  where  there  is  not  much 
restlessness,  distension  of  abdomen,  and  not  more  than  four  or  five  loose 
stools  during  the  day,  it  will  be  usually  sufficient  to  underfeed  them  for  a  day 
or  two,  and  give  them  some  mild  laxative,  as  carbonate  of  magnesia  or 
rhubarb  and  soda.  Infants  at  the  breast  may  be  given  a  few  teaspoonfuls  of 
sweetened  barley  water  in  lieu  of  the  breast,  or  after  they  have  been  partially 
satisfied  at  the  breast.  Bottle-fed  children  should  have  a  low  percentage  of 
proteid  in  their  food,  such  as  a  weak  cream  mixture  (see  p.  50)  if  the  stools 
are  loose  and  curdy. 

If  the  purging  is  at  all  severe  and  curdy  masses  are  vomited,  or  appear 
in  the  stools,  it  will  be  best  at  once  to  withhold  all  milk  for  a  day  or  two, 
and  to  substitute  some  more  digestible  and  less  fermentable  food,  such,  for 
instance,  as — 

Arrowroot  water 2  ounces 

Whey 2      „ 

White  sugar i  teaspoonful 

or — 

Barley  water 10  ounces 

White  of  e^g ^  ounce 

White  sugar  .         .         .         .         .         .         .  i  or  two  teaspoonfuls 

Either  of  these  maybe  given  out  of  a  bottle  every  few  hours,  and  in  amounts 
according  to  age.     Veal  broth  is  also  very  useful. 

The  medicinal  treatment  in  the  early  stage  consists  in  giving  a  laxative 
for  the  first  twelve  or  twenty-four  hours.  In  these  cases  the  diarrhoea  is 
probably  the  result  of  a  congestion  of  the  mucous  membrane  of  the  intestine, 
and  of  the  presence  of  irritating,  perhaps  putrescent  materials,  and  it  is  wiser  to 
assist  elimination  than  attempt  to  prevent  it  by  means  of  opium  or  astringents. 
To  this  end  emulsion  of  castor  oil  or  small  doses  of  calomel  (g-  to  7  grain) 


88  Diseases  of  the  Digestive  System 

may  be  given,  the  latter  being  preferable  if  there  is  vomiting,  on  account  of 
its  being  more  readily  retained  by  the  stomach.     (F.  17.) 

By  the  end  of  twenty-four  or  forty-eight  hours  the  laxative  will  have  done 
all  that  can  be  expected  of  it,  and  if  the  stools  are  yellow,  homogeneous,  and 
less  frequent,  a  sedative  may  now  be  useful,  such  as  bismuth  and  small 
doses  of  opium.     (F.  18,  F.  19.) 

In  the  majority  of  cases  of  simple  diarrhoea  the  attack  is  arrested  by 
these  means — namely,  a  liquid  diet  in  which  milk  is  excluded  or  given 
sparingly,  and  a  laxative  for  a  day  or  two  followed  by  bismuth  or  zinc.  It 
not  unfrequently  happens,  however,  that  a  simple  diarrhuea  without  urgent 
symptoms  passes  suddenly  into  the  acute  or  inflammatory  form,  or,  on  the 
other  hand,  it  may  end  in  a  more  or  less  chronic  condition  of  looseness  of 
bowels  with  marked  loss  of  flesh.  As  improvement  takes  place  diluted 
milk  may  be  allowed  in  small  quantities,  or,  what  is  useful  and  readily  pre- 
pared, milk  diluted  with  twice  its  bulk  or  an  equal  quantity  of  arrowroot 
water  (a  teaspoonful  to  10  oz.)  and  sweetened  with  white  sugar.  Malt 
extract  may  be  added  a  few  minutes  before  the  food  is  taken.  During 
convalescence,  diluted  acids  with  pepsine  or  astringents  are  the  best  remedies. 
(F.  20,  F.  21.) 

Constipation. — Constipation  is  one  of  the  minor  troubles  which  are  of 
most  frequent  occurrence  during  infancy,  and  for  which  the  advice  of  the 
practitioner  is  sought.  Both  breast-fed  and  artificially  fed  infants  suffer, 
though  the  latter  far  more  frequently  and  severely  than  the  former.  The 
healthy  infant  passes  two  or  three  semi-liquid  homogeneous  orange- coloured 
stools  daily  without  effort  or  straining,  while  some  infants  appear  to  have  a 
difficulty  in  defecation  from  want  of  expelling  power,  but  at  once  pass  a 
fairly  healthy  stool  if  the  colon  is  reflexly  stimulated  by  inserting"  a  small 
suppository  into  the  rectum.  In  the  majority  of  cases,  however,  in  which 
constipation  exists,  the  stools  are  dry  and  pale  with  an  excessive  quantity  of 
mucus,  and  an  evacuation  only  occurs  once  a  day,  or  perhaps  once  every  two 
or  three  days.  There  is  usually  much  straining  before  the  stool  is  passed, 
and  perhaps  some  mucus  tinged  with  blood  may  accompany  or  follow  the 
stool.  Infants  who  suffer  much  from  constipation  are  often  anaemic,  but 
they  are  by  no  means  always  badly  nourished  as  far  as  fat  is  concerned. 

In  the  majority  of  cases  it  is  the  result  of  a  want  of  tone  in  the  large 
bowel,  which  in  chronic  cases  may  be  dilated,  the  peristaltic  action  being 
sluggish  and  not  easily  evoked  ;  perhaps  also  the  intestinal  juices  are  scanty 
and  the  bile  deficient  in  quantity.  In  some  cases  constipation  is  due  to  a 
deficiency  of  fat  in  the  food  ;  the  fasces  normally  contain  fat,  and  it  appears,  to 
act  as  a  natural  purgative.  Fluid  fasces  in  the  colon  seem  much  more 
readily  to  excite  peristalsis  than  solid  fsecal  matters.  Infants  who  are  con- 
stipated usually  have  abnormally  distended  abdomens,  and  faecal  masses 
may  often  be  felt  in  the  transverse  and  descending  colon.  In  some  cases 
constipation  is  distinctly  hereditary  ;  mothers  who  suffer  much  from  this 
trouble  often  have  infants  who  also  suffer  in  this  way.  It  must  not  be  for- 
gotten that  narcotics  in  small  doses  constipate,  and  bromides — though  in  less 
degree — have  the  same  effect. 

Constipation  is  a  frequent  trouble  in  children  as  well  as  in  infants.  Fat, 
rickety  children,  who  are  late  in  walking,  very  frequently  suft'er  in  this  way. 


Constipation  89 

In  some,  constipation  and  looseness  of  bowels  alternate  with  each  other.  It 
mostly,  perhaps,  occurs  in  those  children  where  milk  in  too  large  quantities 
is  given  and  is  not  well  digested,  as  evidenced  by  the  large  solid  pasty 
stools.  In  older  children  it  occurs  in  those  who  take  little  exercise,  and 
who  have  large  appetites  ;  though  in  some  of  these  cases  it  appears  to  be 
hereditary.  If  an  infant  at  the  breast  suffers  from  constipation,  care  should 
be  taken  to  first  inquire  into  the  diet  and  habits  of  the  mother  or  wet  nurse. 
An  analysis  of  the  milk  may  be  made  to  determine  the  amount  of  fat,  it  may 
be  necessary  for  the  mother  to  take  more  in  the  way  of  stewed  fruits  or  some 
laxative  medicine,  such  as  confection  of  senna  or  cascara.  In  some  cases 
the  infant's  stools  may  be  fairly  normal,  and  the  infant  appears  to  suffer  from 
a  want  of  expelling  power  ;  this  may  be  overcome  by  gentle  friction  of  the 
abdomen  with  the  oiled  hand,  or  it  may  be  necessary  to  reflexly  stimulate 
the  colon  and  abdominal  muscles  by  introducing  into  the  rectum  a 
small  piece  of  soap  or  glycerine  suppository.  In  artificially  fed  infants  of 
feeble  digestive  powers,  treatment  is  often  much  less  successful.  The  first 
consideration  is  the  diet  ;  this  will  probably  have  to  be  changed  in  the 
direction  of  diminishing  the  quantity  of  curd,  increasing  the  amount  of  fat, 
and  adding  some  form  of  malted  food  or  extract  of  malt.  The  best  diet  for 
constipation  is  one  which  is  well  digested  and  which  contains  the  food 
elements  in  proper  proportion.  What  is  wanted  is  a  better  tone  in  the 
large  bowel.  Oatmeal  water,  or  a  small  quantity  of  finely  ground  oatmeal 
added  to  each  bottle,  may  have  the  desired  effect.  Persistent  and  carefully 
applied  massage  to  the  abdomen  by  a  trained  nurse  is  of  much  value  in 
obstinate  cases  of  habitual  constipation.  Enemata  of  glycerine  and  water 
(5SS-5J)  or  olive  oil  are  preferable  to  medicines  for  habitual  use.  Glycerine 
suppositories  are  often  successful,  or  suppositories  containing  \ — h  grain  of 
belladonna  may  be  used.  Bitter  and  nauseous  medicines  are  to  be  avoided 
as  far  as  possible,  for  it  is  more  than  likely  they  will  not  be  persevered  with 
by  the  nurse  or  friends.  In  many  cases  two  to  three  grains  of  car- 
bonate of  magnesia  or  a  teaspoonful  or  two  of  fluid  rhagnesia  given  several 
times  a  day  in  milk  will  be  all  that  is  necessary,  for  infants.  When  these 
fail,  small  doses  of  calomel  {^\  grain)  twice  a  day  for  a  few  days  will,  if  aided 
by  enemata,  often  succeed  in  bringing  about  a  more  satisfactory  state  of 
things,  for  a  while  at  least.  The  aromatic  syrup  of  cascara  (B.P.)  in  doses  of 
1 5  to  30  minims  twice  a  day  is  often  of  service.  We  have  often  found  liq. 
helaline  and  pepsine  or  liq.  euonymin  and  pepsine  in  15  to  20  minim  doses 
very  useful  in  the  constipation  of  infants  and  children. 

In  older  children  the  diet  must  be  carefully  regulated  ;  pastry,  salt  meat, 
and  sweets  must  be  forbidden,  while  oatmeal,  green  cooked  vegetables, 
stewed  fruit,  orange  juice,  stewed  prunes  and  figs,  may  be  given  with  dis- 
cretion. Sponging  with  cold  water  in  the  morning,  plenty  of  outdoor 
exercise,  and  only  a  moderate  amount  of  brain  work,  should  be  insisted  on. 
Of  medicines,  the  most  efficacious  are  some  of  the  mineral  waters,  such  as 
Rubinat,  yEsculap,  Franz  Josef,  given  in  warm  water  or  milk  overnight  or  the 
first  thing  in  the  morning.  Granules  containing  \  grain  of  aq.  extract  of 
aloes  or  calomel  \  grain,  with  ex.  coloc.  co.  f  grain,  are  useful  ;  or  \  grain  of 
res.  podophylli.  But  we  frequently  find  in  practice  that  children  will  neither 
take  mineral  waters  nor  granules,  and  we  have  to  fall  back  on  such  drug 


go  Diseases  of  the  Digestive  System 

sweetmeats  as  cascara  chocolate  bonbons,  or  '  tamar  indien  '  lozenges,  which 
are  pleasant  to  take,  and  in  some  instances  at  least  effectual. 

The  B.  and  W.  tabloids  of  cascara  or  cascara  comp.  or  bi-palatinoids 
(Oppenheimer)  containing  aloes,  nux  vomica,  and  belladonna  &c.  are  readily 
taken  by  older  children.  In  anaemia  with  constipation  the  old-fashioned 
mixtm-e  of  ferrous  sulphate  and  mag.  sulph.  is  very  efficacious,  but  nauseous. 
(F.  22,  F.  23,  F.  25.) 

Vomiting' — Acute  Gastric  Catarrh 

If  a  child  is  suddenly  attacked  with  vomiting  and  high  fever,  the 
probability  is  strong  that  the  symptoms  are  due  to  the  onset  of  some  zymotic 
disease,  such  as  scarlet  fever  or  epidemic  influenza,  or  some  meat  or  milk 
poisoning.  In  infants  the  symptoms  may  indicate  the  onset  of  the  so-called 
'  cholera  infantum,'  or  zymotic  diarrhoea.  In  any  such  case,  inquiry  must  be 
made  as  to  the  food  the  child  has  taken  during  the  few  hours  preceding  the 
attack,  as  well  as  to  the  possibility  of  a  scarlet-fever  infection,  and  the  throat 
and  skin  must  be  carefully  inspected.  But  apart  from  any  zymotic  disease 
some  children  seem  prone  to  these  fever-vomiting  attacks,  or '  bilious  attacks  ' 
as  they  are  sometimes  called  ;  there  is  headache,  nausea,  vomiting,  and 
fever  ;  the  stomach  may  reject  first  some  undigested  food,  then  more  or  less 
bile-stained  fluids.  In  a  few  days  the  attack  passes  off,  and  the  child  is 
perhaps  better  in  health  than  it  was  before  the  attack,  the  vomiting  and 
thorough  emptying  of  the  stomach  having  had  a  distinctly  salutary  effect.  A 
few  months  after  there  is  perhaps  another  attack. 

In  acute  gastro-enteritis,  the  result  of  taking  some  toxines  from  meat  or 
milk,  the  vomiting,  colic,  and  diarrhoea  are  often  excessive.     (See  p.  loi.) 

Some  of  these  attacks  are  doubtless  due  to  an  acute  gastric  catarrh, 
brought  on  by  an  error  in  diet  or  perhaps  exposure  to  cold,  in  others  the 
etiology  is  quite  obscure.  Probably  in  some  cases  these  '  cyclic '  attacks 
are  really  '  neurotic '  rather  than  '  bilious,'  and  we  have  known  cases  in 
children  who  have  had  attacks  of  vomiting  lasting  a  day  or  two  or  more  and 
recurring  every  i&^  weeks,  perhaps  for  years,  but  gradually  becoming  less 
frequent  as  the  children  grow  older. 

In  all  cases  of  acute  vomiting  it  is  important  to  give  the  stomach  a 
temporary  rest  by  avoiding  all  food  or  fluids,  and  giving  a  little  ice  by  the 
mouth  till  the  vomiting  ceases.  Rectal  alimentation  may  be  resorted  to  if 
necessary.  Veal  broth  and  peptonised  milk  are  the  most  likely  foods  to 
be  retained  by  the  stomach,  but  it  is  not  wise  to  attempt  to  give  food  by  the 
mouth  too  soon.  Small  doses  of  calomel  are  useful  if  the  bowels  are 
confined  ;  dilute  hydrocyanic  acid  and  also  phenacetin  are  useful  in  checking 
the  vomiting.     (F.  26,  27.) 

Acute  Gastro-intestinal  Infection.     Inflammatory  or  Zymotic 
Diarrhoea.      Cbolera  Infantum 

With  the  commencement  of  the  warm  weather  in  June  or  July  theie  is 
an  increase  in  the  number  of  cases  of  infantile  diarrhoea  ;  and  by  the  time 
the  end  of  July  or  the  beginning  of  August  is  reached — especially  if  the 
weather  is  close  and  dry — there  is  tolerably  certain  to  be,  in  large  cities,  an 


G  astro -ill  testinal  Infectio  n 


91 


epidemic  prevalence  of  diarrhoea.  It  must  be  within  the  experience  of  all 
that  the  diarrhoeal  diseases  are  commoner  in  summer  than  in  winter,  and, 
moreover,  that  there  is  more  diarrhoea  in  a  hot  dry  summer  than  in  a 
cold  and  damp  one.  The  following  figures  show  these  facts  in  a  forcible 
manner  ;  they  are  taken  from  the  records  of  the  Children's  Dispensary, 
Manchester  :  ' 


Monthly  Adiiiissioits  of  Cases  of  Diarrha'a  for  the  year  1880. 


- 

No.  of  cases 

No.  of  deaths 

Mean  lowest 

and  mean  highest 

temperature 

January 
February 
March 
April  . 
May    . 
June    . 
July    . 
August 
September 
October 
November 
December 

12 

24 

19 

26 

19 

45 
89 
362 
264 
62 
18 
13 

I 

2 
4 

33 
43 
13 

0 

26-41  F. 

34-52 
34-57 
37-59 
39-64 
47-72 

52-72 
55-75 
51-73 
37-58 
28-53 
33-52 

Total     .... 

953 

96 

— 

These  figures  show  that  there  are  at  all  times  of  the  year  a  certain 
number  of  cases  being  brought  for  medical  aid  on  account  of  diarrhoea, 
the  number  being  fairly  constant  during  the  first  five  months  and  the 
last  two  months  of  the  year  ;  with  the  warm  weather  of  June  the  number 
increases,  reaching  its  maximum  in  the  hottest  weather  of  August,  then 
declining  to  the  normal  number  in  the  last  two  months  of  the  year.  The 
year  1880  was  a  more  than  usually  hot  summer  for  this  country,  but  other 
years  show  the  same  relations  between  the  diarrhoeal  disease  of  the  winter 
and  summer  months,  though  in  cooler  summers  the  disproportion  is  not  so 
great. 

The  same  story  is  told  by  the  mortality  tables  of  diarrhoea  in  Berlin 
(Baginsky),  in  New  York  (Siebert),  and  also  in  Baltimore  (Miller)  ;  but  in 
these  cities  the  greatest  mortality  is  in  July,  which  is  their  hottest  month, 
while  in  this  country  August  is  usually  the  hottest  month,  and  the  month  when 
diarrhoea  is  most  prevalent.  The  above  table  bears  out  the  general  statement 
that  diarrhoea  begins  to  be  prevalent  whenever  the  average  temperature  of 
the  twenty-four  hours  reaches  60°  F.,  and  whenever  this  average  tempera- 
ture is  exceeded  by  only  a  few  degrees,  diarrhoea  prevails  in  a  widespread 
epidemic. 

A  similar  table  showing  the  corresponding  number  of  cases  of  bronchial 
catarrh  and  bronchitis  would  show  that  these  diseases  were  more  prevalent  and 

1  By  '  diarrhoea'  are  meant  those  cases  in  which  diarrhoea  was  a  prominent  symptom. 


92  Diseases  of  the  Digestive  System 

fatal  during  the  cold  and  damp  months  of  the  year  than  in  the  warm  and  dry  ' 
months  ;  and  it  has  been  argued  that,  just  as  bronchitis  is  produced  by 
exposure  to  cold  and  damp,  so  diarrhoea  is  caused  by  a  high  temperature,, 
giving  rise  to  an  intestinal  catarrh  or  to  a  'heat  stroke.'  But  there  are  facts 
to  show  that  the  explanation  is  not  so  simple  as  this.  It  is  certain  that 
a  single  exposure  to  a  high  atmospheric  temperature  does  not  give  rise  to  an 
intestinal  catarrh  ;  that  hot  weather  does  not  at  once  increase  the  number 
of  cases  of  diarrhoea,  it  is  only  after  a  high  temperature  has  continued  for 
some  days  ;  and  that  infants  at  the  breast,  especially  those  under  three 
months,  though  exposed  to  the  same  conditions  of  temperature,  are  only 
exceptionally  attacked. 

Summer  diarrhoea  is  much  more  prevalent  and  fatal  in  large  cities  than 
in  country  districts,  and  among  the  poorest  classes  who  live  in  back-to-back 
houses  in  crowded  courts  and  low-lying  districts,  while  it  is  much  less  common 
among  the  better-housed  classes  of  society,  especially  among  those  who  live 
in  the  country  or  suburbs  and  upon  a  high  and  bracing  site. 

It  is  most  prevalent  between  the  ages  of  three  months  and  two  years. 
The  infants  who  suffer  most  are  the  weakly  and  dyspeptic  ones,  who  are 
perhaps  already  suffering  from  an  intestinal  catarrh,  and  who  are  badly  fed 
and  improperly  cared  for — such,  for  instance,  as  the  illegitimate  class  of 
infants  who  are  put  out  to  nurse.  The  infants  who  suffer  least  are  the 
breast-fed  infants  ;  thus  out  of  nearly  2,000  fatal  cases  recorded  by  Emmet 
Holt,  only  some  3  per  cent,  had  been  breast-fed  ;  the  same  result  has  been 
arrived  at  by  the  investigations  of  Dr.  Niven  of  Manchester.  This  immunity 
is  no  doubt  due  to  the  fact  that  the  milk  they  take  is  '  sterile,'  and  not  swarm- 
ing with  organisms  as  cow's  milk  is  apt  to  be. 

The  epidemic  prevalence  of  summer  diarrhoea  has  been  attributed,  with 
more  or  less  plausibility,  to  the  ingestion  of  sour  milk,  unripe  fruit,  inhalation 
of  sewer  gas,  emanations  from  the  soil ;  and  possibly  each  of  these  may 
contribute  to  the  cases  of  diarrhoea.  That  they  are  not  the  constant  and 
invariable  cause  is  certain,  as  infants  fed  on  sour  milk  by  no  means  invariably 
suffer  from  diarrhoea,  and  the  epidemic  is  too  widespread  to  be  explained  on 
the  unripe  fruit  theory  ;  and,  moreover,  diarrhoea  is  not  especially  prevalent 
in  some  towns  where  sewer  gas  is  constantly  present  in  the  houses  (Ballard). 
While  it  is  certain  that  the  ordinary  lactic  acid  changes  occurring  in  milk 
when  It  turns  sour  are  not  the  cause  of  diarrhoea,  yet  there  is  a  strong 
probability  that  milk  often  is  the  vehicle  by  means  of  which  certain  micro- 
organisms or  poisons  enter  the  system,  and  give  rise  to  the  symptoms  which 
are  present  in  diarrhoea. 

That  the  diarrhoeal  diseases  are  epidemic  in  hot  weather  is  certain.  Are 
any  of  the  forms  also  infectious  ?  In  some  recorded  cases  it  certainly  appears 
this  has  been  so.  Dr.  Bruce  Low  '  gives  an  account  of  four  different  out- 
breaks of  diarrhoea  in  which  it  appears  that  the  disease  was  communicated 
by  contagion.  It  can  easily  be  understood  that  the  stools  of  infants  suffer- 
ing from  diarrhoea  may  infect  others. 

There  can  be  Httle  doubt  that  the  immediate  cause  of  infantile  diarrhoea 
is  an  infection  of  the  alimentary  canal  by  various  loxine-producing  bacteria, 

1  Supplement  to  the  Seventeenth  Annual  Report  of  the  Local  Government  Board, 
1881-1888. 


Gastro-intcstinal  Infection  93 

contained  in  milk  or  other  forms  of  food.  No  specific  organism  has  been 
detected,  but  the  investigations  of  Booker  and  others  point  to  the  streptococci 
and  Proteus  vulgaris  as  being  among  the  chief  performers.  Some  however 
believe  that  the  normal  bacteria  of  the  alimentary  canal,  such  as  B.  coli 
communis  and  B.  lactis  aerogenes,  which  are  universally  present  in  the  stools 
of  infants  fed  on  milk,  will,  under  certain  circumstances,  take  on  a  condition 
of  virulency  and  produce  toxines.  The  entrance  of  the  bacteria  into  the 
stomach  and  intestines  marks  the  commencement  of  the  attack,  for  if  the 
conditions  are  favourable  toxines  of  more  or  less  virulence  are  formed.  The 
action  of  the  toxines  is  twofold  :  when  absorbed  into  the  blood  they  produce 
such  symptoms  as  fever,  depression  of  the  heart's  action,  albuminuria,  &c., 
while  locally  they  produce  irritation  of  the  stomach  and  intestines,  giving  rise 
to  vomiting  and  diarrhoea,  and  later  by  their  corrosive  action  set  up  an  inflam- 
matoiy  state  of  the  mucous  membrane  of  the  lower  end  of  the  alimentary 
canal  followed  by  ulceration. 

Symptoms. — The  symptoms  may  supervene  suddenly  in  an  infant  in 
apparent  health,  though  more  frequently  an  infant  is  attacked  who  has 
already  suffered  for  a  day  or  two  from  intestinal  disturbance  or  has  had  an 
attack  of  diarrhoea  a  week  or  two  before.  The  first  symptom  is  generally 
vomiting  ;  this  is  followed  by  a  loose  motion  and  accompanied  by  more  or 
less  fever,  at  the  same  time  the  infant  is  restless  and  irritable,  the  abdomen 
is  distended  with  gas,  and  the  legs  are  drawn  up.  The  vomiting  in  the 
severest  cases  is  very  distressing,  everything  taken  being  rejected  imme- 
diately, the  vomited  matters  consisting  of  undigested  food,  and  subsequently 
of  simple  mucus  tinged  with  bile  ;  the  stools  are  watery  and  consist  of  undi- 
gested food  ;  they  are  usually  at  first  yellow  and  frothy,  or  green,  containing 
lumps  orflocculi  of  curd.  Later,  in  severe  cases,  they  consist  of  little  else 
than  slightly  coloured  water,  or  resemble  the  rice  stools  of  cholera,  and  as 
the  attack  becomes  more  chronic  they  are  of  a  dirty  brown  colour  and  very 
offensive.  The  tongue  becomes  coated  with  a  thick  white  fur,  the  thirst  is 
mostly  extreme,  the  child  eagerly  taking  the  bottle  or  spoon,  but  vomiting 
immediately  afterwards  ;  there  is  great  restlessness,  the  child  may  doze  for  a 
short  time,  but  rarely  manages  to  get  off  into  a  sound  sleep. 

The  fever  is  seldom  high  and  mostly  intermittent,  varying  from  99°  F.  to 
102°  F.,  in  exceptional  cases  105°  F.  or  still  higher.  The  stools  become  more 
and  more  frequent  as  the  disease  advances,  sometimes  being  passed  every  few 
minutes,  perhaps  escaping  unconsciously  or  being  preceded  by  a  short  cry  or 
an  expression  of  pain  in  the  infant's  face.  Very  often  more  or  less  erythema 
or  excoriation  occurs  about  the  anus  or  genitals.  After  a  longer  or  shorter 
period,  according  to  the  acuteness  of  the  case,  symptoms  of  collapse  make 
their  appearance.  There  is  a  change  in  the  infant's  face  which  strikes  the 
most  casual  observer  ;  the  eyes  are  sunk  in  the  head  and  kept  partly  closed, 
the  fontanelle  is  depressed,  the  face  is  pallid  or  of  an  earthy  tinge,  the  muscles 
of  the  neck  and  limbs  lose  their  tonus,  and  the  head  rolls  about  when  the 
infant  is  moved.  There  is  no  longer  any  great  restlessness,  the  infant  is 
generally  listless  and  drowsy,  and  takes  little  or  no  notice  of  its  friends.  In 
this  stage  the  vomiting  usually  ceases,  the  stools  become  less  frequent  and 
are  smaller,  and  the  abdomen  becomes  sunken  and  its  walls  flabby. 

The  further  progress  of  the  attack  depends  upon  whether  improvement 


94  Diseases  of  the  Digestive  System 

sets  in  ;  if  so,  the  diarrhcea  ceases,  more  or  less  colour  returns  to  the  infant's 
face,  it  takes  notice  of  its  friends,  and,  though  still  weak,  begins  to  use  its 
limbs  and  take  its  food.  In  other  cases  it  becomes  more  exhausted,  it  wastes 
rapidly,  parasitic  stomatitis  makes  its  appearance,  and  frequently  convul- 
sions occur,  which  quickly  bring  the  end.  The  fatal  event  is  often  preceded 
by  the  occurrence  of  cerebral  symptoms,  such  as  coma  and  Cheyne- Stokes 
respiration,  a  condition  which  has  been  termed  '  false  hydrocephalus '  from 
its  resemblance  to  meningitis,  and  indeed  it  is  often  believed  by  the  friends 
and  others  that  death  has  occurred  through  'water  on  the  brain.'  In 
this  state  the  coma  is  profound,  the  pupils  dilated,  and  at  times  unequal, 
the  respirations  irregular,  the  child  is  pulseless,  and  there  may  be  twitchings 
of  the  face  or  limbs.  The  state  of  the  fontanelle  will  generally  assist  the 
diagnosis  in  deciding  whether  the  cerebral  symptoms  are  due  to  arterial 
anaimia  of  the  brain,  as  in  false  hydrocephalus,  or  to  meningitis  ;  in  the 
former  case  the  fontanelle  is  depressed  below  the  level  of  the  cranial  bones, 
inasmuch  as  the  brain  occupies  less  space  than  normally,  in  consequence 
of  the  arterial  system  being  nearly  empty,  the  result  of  a  failing  heart. 

The  length  of  time  the  disease  lasts  differs  considerably.  So  rapidly  fatal 
are  some  attacks  that  the  term  cholera  infantum  has  been  applied  to  them, 
and  indeed  in  a  few  instances  this  resemblance  to  Asiatic  cholera  is  very 
close  indeed.  Such  cases  occur  much  more  commonly  in  the  large  cities  of 
the  continents  of  Europe  and  America  than  in  our  own  cooler  climate. 

The  following  case  may  be  taken  as  an  instance  : 

A  boy  of  five  years  of  age  was  taken  suddenly  ill  with  vomiting  and  purging  at  i  A.M. 
and  died  at  2.45  p.m.  on  the  same  day.  When  admitted  to  hospital  at  11  A.M.  he  was 
completely  collapsed  ;  the  pupils  contracted,  the  conjunctivag  nearly  insensible,  the  lips 
were  pallid,  the  pulse  could  hardly  be  counted,  the  temperature  was  104°  F.  In  spite  of 
brandy,  ammonia,  and  nitrite  of  amyl,  he  failed  to  rally.  The  fast- mortetn  examination 
showed  the  body  to  be  well  nourished  and  rigor  mortis  strongly  marked.  The  intestines 
were  distended  with  gas,  and  contained  a  small  quantity  of  pale  gelatinous  fluid,  the 
mucous  membrane  of  the  whole  length  of  the  alimentary  canal  was  pink  with  minute 
extravasations  of  blood,  and  the  solitary  glands  were  enlarged.  The  tissues  generally  were 
pale  and  dry.  The  case  occurred  in  August  1880,  a  summer  which  was  unusually  hot, 
and  during  which  zymotic  diarrhoea  was  very  prevalent. 

In  a  few  cases,  convulsions  may  supervene  during  the  first  few  days,  and 
bring  about  a  fatal  termination.  In  the  majority  of  fatal  cases  the  duration 
is  somewhat  longer,  perhaps  a  week  to  ten  days,  the  infant  passes  through 
the  acute  attack,  the  symptoms  then  assume  more  or  less  of  a  dysenteric 
character,  and  it  succumbs  through  exhaustion  and  inanition  from  a  failure 
of  the  ahmentary  canal  to  recover  its  normal  functions.  Many  infants  who 
escape  with  life  in  August,  die  in  September  or  October  from  gastro- 
intestinal atrophy,  which  has  followed  as  the  result  of  the  acute  attack. 

Complications. — By  far  the  most  common  complication  of  acute  intes- 
tinal catarrh  is  broncho-pneumonia,  or  bronchitis  and  collapse  of  lung.  The 
symptoms  are  apt  to  be  latent,  but  any  dyspnoea  or  high  temperature  would 
necessarily  call  for  a  careful  examination  of  the  lungs.  Thrombosis  of  the 
cerebral  sinuses  occasionally  takes  place  in  the  later  stages,  but  it  is  com- 
paratively rare  ;  the  symptoms  consist  in  distension  of  the  veins  emptying 
into  the  cavernous  sinus  with  oedema  of  the  forehead  and  eyelids  ;  there 


G astro-intestinal  Infection  95 

will  also  be  tonic  spasm  of  the  limbs  and  neck,  and  convulsions.  Albu- 
minuria frequently  occurs  during  acute  diarrhoea  ;  nephritis  and  uriemic 
convulsions  have  been  described  by  some  authors  ;  but  we  do  not  think  the 
convulsions  which  frequently  occur  towards  the  last  areurjemic.  Peritonitis 
occasionally  occurs,  hyperpyrexia  may  also  occur. 

Sequelce. — Should  the  infant  recover  from  the  acute  attack,  it  is  by  no 
means  certain  that  complete  recovery  will  take  place  ;  for  it  is  extremely 
probable  that  gastro-intestinal  atrophy  may  supervene,  or  a  chronic  diarrhoea 
remain,  the  result  of  chronic  catarrh  with  follicular  ulceration  of  the  colon, 
sigmoid  flexure,  and  rectum.  In  the  latter  case  the  symptoms  are  those  of 
dysenteric  diarrhcea  ;  defalcation  is  frequently  accompanied  by  much  pain 
and  straining,  the  stools  consist  of  mucus,  often  tinged  with  blood,  or  are  dark 
brown  and  liquid.  The  rectum  becomes  prolapsed,  and  is  sometimes  returned 
with  difficulty,  and  the  child  rapidly  wastes.  Not  infrequently  we  see  children, 
usually  under  two  years  of  age,  who  have  gone  through  a  severe  attack  of 
diarrhcea,  extremely  anaemic,  and  whose  subcutaneous  tissues,  including  the 
face,  are  oedematous.  In  such  cases  a  ti^ace  of  albumen  may  be  found  in  the 
urine,  but  it  is  usually  free  from  albumen.  They  have  been  described  by  some 
authors  as  suffering  from  nephritis.  Our  own  experience  is  that  the  kidneys  in 
such  cases  show  very  little  pathological  change,  and  moreover  urine  is  freely 
secreted  during  life.  This  sequela,  whatever  may  be  the  pathology  of  it,  is,  we 
are  inclined  to  believe,  the  result  of  ptomaine  poisoning. 

Diagnosis. — The  principal  difficulty  in  diagnosis  occurs  in  the  acute  form 
of  the  disease,  as  it  may  be  confounded  with  acute  scarlet  fever,  sunstroke, 
or  irritant  poisoning,  such  as  from  eating  poisonous  fungi.  We  have  several 
times  been  requested  by  a  coroner  to  make  a  post-7nortem  on  a  child  who 
has  been  seized  with  vomiting,  purging,  and  high  fever,  with  great  depres 
sion.  followed  by  death  in  a  few  hours  ;  and  we  have  been  unable  to  say 
for  certain,  from  the  post-mortem  appearance,  whether  the  death  has  been 
due  to  malignant  scarlet  fever  or  acute  inflammatory  diarrhoea.  The  pro- 
blem has  been  solved  in  some  instances  by  the  occurrence  of  scarlet  fever 
in  the  same  house  shortly  afterwards.  In  the  majority  of  cases  the  appear- 
ances seen  in  the  throat  would  suffice  for  diagnosis.  The  diagnosis  between 
sunstroke  and  acute  cases  of  cholera  infantum  may  be  difficult,  as  there  may 
be  a  high  temperature  in  both  ;  but  in  most  instances  the  gastro-intestinal 
disturbance  is  much  more  marked  in  the  latter  than  the  former.  It  must  be 
borne  in  mind  that  some  consider  cholera  infantum  to  be  really  cases  of 
'  heat  stroke.' 

Prognosis. — Acute  intestinal  catarrh  must  always  rank  as  a  serious 
disease,  not  only  from  its  tendency  to  prove  fatal  during  the  attack  itself,  but 
because  it  so  frequently  passes  on  into  a  subacute  or  chronic  form  of  catarrh 
to  be  succeeded  by  atrophy.  The  younger  the  infant,  the  more  serious  the 
prognosis  becomes,  especially  if  it  has  been  artificially  fed  ;  in  older  childi'en, 
though  the  attack  may  be  severe  and  the  depression  produced  very  great, 
the  disease  usually  terminates  favourably.  The  onset  of  cerebral  symptoms 
is  of  very  unfavourable  augury,  and  the  chances  are  against  the  infant 
though  the  case  is  not  hopeless.  Convulsions  are  generally  followed  by  death. 
In  those  cases  in  which  infants  lapse  into  the  chronic  stage  the  prognosis  is 
serious,  as  they  are  already  exhausted  by  the  acute  attack. 


96  Diseases  of  the  Digestive  System 

Morbid  Anatomy. — If  death  has  taken  place  early  in  the  disease,  the 
body  is  well  nourished  and  perhaps  even  plump,  but  the  face  retains 
the  same  expression  it  had  during  life,  the  eyes  and  cheeks  being  sunken. 
On  opening  the  body,  minute  hcemorrhages  are  usually  present  on  the  sur- 
face of  the  lungs  and  heart,  and  there  is  hypostatic  congestion  at  the  bases 
of  the  lungs.  The  mucous  membrane  of  the  stomach  and  bowels  is  swollen 
and  pink  from  capillary  congestion,  the  congestion  often  being  present  in 
patches,  and  minute  haemorrhages  may  have  taken  place.  The  mucous 
membrane  of  the  large  intestine  is  congested,  especially  along  the  summit  of 
the  folds  of  the  membrane.  An  excess  of  mucus  is  generally  present,  and 
the  contents  are  liquid.  The  Peyer's  patches  and  solitary  glands  are  most 
frequently  swollen  ;  the  kidneys  are  pale,  the  cortex  frequently  enlarged. 
In  the  later  stages,  the  body  is  more  or  less  emaciated,  the  lungs  are  semi- 
solid at  their  bases  from  the  presence  of  catarrhal  pneumonia,  the  mucous 
membrane  of  the  small  intestine  is  swollen  and  congested,  but  the  principal 
changes  will  be  noted  in  the  large  intestines.  Here  the  mucous  membrane 
is  generally  much  congested,  especially  about  the  caecum  and  descending 
colon,  there  may  be  superficial  ulceration  or  excoriation  at  the  summits  of 
the  folds  of  mucous  membrane,  or  the  bowel  may  be  pitted  with  deep  but 
small  ulcers  from  the  results  of  breaking  down  and  discharge  of  the  solitary 
glands.  Microscopical  examination  of  the  intestines  shows  a  distension  of 
the  network  of  capillaries  of  the  villi  and  mucous  membrane,  and  an  exuda- 
tion of  leucocytes  is  mostly  present  in  the  submucosa  and  between  the 
tubules  or  crypts  of  Lieberkuhn.  Numerous  micro-organisms  are  present. 
The  solitary  glands,  especially  in  the  large  bowel,  are  very  often  in  a  state  of 
softening  in  their  centres,  or  their  contents  have  discharged,  giving  I'ise  to 
sharply  cut  ulcers. 

On  examining  the  brain,  no  constant  or  indeed  definite  lesion  is  found  ; 
in  most  cases  the  sinuses  are  distended  with  blood  or  occupied  by  a  firm  pale 
clot,  but  this  condition  of  engorgement  appears  to  be  the  result  of  death 
taking  place  through  cessation  of  respiration,  or  during  a  convulsion,  and  is 
due  to  mechanical  causes  from  interference  with  the  return  of  blood  to  the 
lungs.  The  symptoms  referable  to  the  brain  during  the  last  few  hours  of 
life,  coma,  Cheyne-Stokes  respiration,  &c.,  have  been  attributed  to  exhaustion, 
and  an  anaemic  (arterial)  condition  of  brain  due  to  diminished  arterial  tension. 
The  suggestion  that  they  are  due  to  uraemia  is  improbable,  though  it  is  not 
unlikely  they  are  due  to  the  absorption  of  ptomaines  from  the  alimentary 
canal.  Meningitis  is  extremely  rare  ;  in  one  case,  however,  which  came 
under  our  notice,  lymph  was  found  about  the  optic  commissures. 

Treatment. — The  most  important  part  of  prophylactic  treatment  is  con- 
nected with  the  food  which  the  infant  takes  and  the  purity  of  the  air  which 
it  breathes.  No  weakly  infant  who  is  being  reared  on  artificial  food  and  who 
has  previously  suffered  from  intestinal  catarrh  ought,  if  it  is  possible  to  avoid 
it,  to  remain  in  the  crowded  part  of  a  large  town  during  the  hot  weather,  but 
should  be  sent  away  to  a  bracing  seaside  place,  or  country  quarters  should 
be  selected  among  breezy  hills.  The  greatest  care  should  be  exercised  in 
the  selection  of  pure  milk  and  in  its  storage  before  it  is  taken  by  the 
patient,  as  there  is  little  doubt  that  milk  readily  absorbs  noxious  gases,  is 
easily  contaminated   by   micro-organisms   present  in  the  atmosphere,  and 


G astro-intestinal  Infection  97 

changes  are  set  up  which  render  it  unfit  for  food.  All  milk  taken  by  infants 
and  children  during  the  summer  months  should  be  carefully  sterilised  in  one 
of  the  milk  sterilisers  sold  for  the  purpose.  Care  must  also  be  taken  that 
the  infant  is  not  given  food  in  excess  of  its  digestive  powers,  as  undigested 
curd  or  other  foods  are  exceedingly  likely  to  decompose  in  the  alimentary 
canal  and  give  rise  to  irritation  and  diarrhoea.  The  stools,  both  of  infants 
at  the  breast  and  bottle-fed  children,  should  be  carefully  watched,  and  any 
traces  of  undigested  food  or  of  unusual  foulness  or  looseness  of  bowels 
should  be  the  signal  for  lessening  the  amount  of  food  taken.  No  infant  at 
the  breast  should  be  weaned  during  the  continuance  of  the  hot  weather, 
and  if  diarrhcea  makes  its  appearance  it  ought,  if  possible,  to  be  returned  to 
the  breast. 

The  indications  for  treatment  when  the  diarrhoea  has  commenced,  are  in 
the  first  place  to  give  a  laxative  to  clear  away  all  irritating  or  decomposing 
foods  and  relieve  the  congested  bowel,  and  secondly  to  give  food  only  of 
the  blandest  character  and  in  small  quantities.  The  first  indication  can  be 
fulfilled  by  giving  castor  oil,  as  long  ago  advocated  by  Dr.  Geo.  Johnson,  or 
by  a  dose  or  two  of  calomel.  The  former  may  be  given  in  emulsion  in  com- 
bination with  an  unirritating  antiseptic,  as  boracic  acid  or  salicylate  of  soda  ; 
the  latter  helps  to  prevent  decomposition  in  the  emulsion,  and  perhaps  also 
plays  a  similar  part  in  the  stomach  in  checking  putrefactive  changes.  (F.  28.) 
The  oil  may  be  given  by  itself  in  half-teaspoonful  or  teaspoonful  doses, 
but  it  is  apt  to  cause  sickness.  Instead  of  the  castor  oil,  especially  if  there 
is  much  sickness,  small  doses  of  calomel  maybe  given,  and  on  account  of  its 
small  bulk  and  tasteless  character  it  is  in  many  respects  to  be  preferred.  It 
is  better,  if  the  attack  is  a  sharp  one,  to  give  it  in  small  and  repeated  doses, 
especially  in  weakly  infants  ;  |  to  ^  grain  may  be  given  to  infants  and 
young  children  every  two  hours,  until  one  or  two  grains  have  been  given. 
In  the  course  of  twelve  hours  or  more,  according  to  the  intensity  of  the 
diarrhoea,  all  appearances  of  undigested  food  will  have  disappeared  from  the 
stools,  the  latter  perhaps  continuing  frequent  and  watery.  Stomach  v/ashing 
and  irrigation  of  the  large  bowel  have  been  largely  practised  both  on  the 
Continent  and  in  America,  and  have  the  great  advantage  of  removing  at  once 
the  contents  of  the  stomach  and  large  bowel,  but  no  irrigation  can  reach  the 
small  intestines. 

Unless  the  infant  be  at  the  breast,  all  milk  or  milk  foods  should  be 
stopped,  and  barley  water  with  white  of  ^'gg  or  weak  chicken  broth  substi- 
tuted (p.  87).  The  most  troublesome  symptom  at  first  is  the  vomiting  ;  this 
may  be  constant,  following  every  attempt  at  feeding,  and  it  will  be  necessary 
to  desist  from  all  attempts  for  some  hours,  only  moistening  the  child's 
mouth  with  a  small  brush  dipped  in  iced  water.  Counter-irritation  and  hot 
applications  to  the  abdomen  at  this  stage  are  undoubtedly  serviceable.  For 
this  purpose  a  liniment  composed  of  five  drops  of  oil  of  mustard  to  an 
ounce  of  camphorated  oil  may  be  gently  rubbed  over  the  abdomen,  or 
spongiopiline  or  several  folds  of  flannel  wrung  out  of  water  at  110°  in  which 
mustard  has  been  diffused  (in  the  proportion  of  two  tablespoonfuls  to  a 
gallon)  may  be  applied. 

The  medical  treatment  of  acute  diarrhoea  is  unsatisfactory.  The  vomit- 
ing may  continue,  the  stools  in  spite  of  the  most  careful  dieting  may  be 

H 


98  Diseases  of  the  Digestive  System 

loose  and  frequent,  and  the  child  rapidly  lose  ground.  It  must,  how- 
ever, be  borne  in  mind  that  the  disease  is  something  more  than  a  congested 
irritable  state  of  bowels,  in  which  the  contents  are  rapidly  passed  downwards 
into  the  colon  and  rectum,  but  the  diarrhoea  is  rather  the  result  of  a  form 
of  irritant  poisoning  by  toxines,  which  must  be  got  rid  of  as  soon  as  possible. 
There  cannot  be  the  least  doubt  that  in  many  cases  with  the  cessation  of  the 
diarrhoea  the  child  becomes  no  better,  but  rapidly  passes  into  a  condition  of 
collapse  with  cerebral  symptoms,  due  in  all  probability  to  toxEemia  ;  or  the 
temperature  rises  and  pneumonia  supervenes. 

The  drug  which  has  appeared  to  us  the  most  successful  in  the  vomit- 
ing in  the  early  stages  is  carbolic  acid,  the  glycerine  of  carbolic  acid  being 
given  in  drop  doses  every  two  hours  or  even  oftener.  Carbolic  acid  has  a 
sedative  action  on  the  stomach,  and  helps  also  to  check  the  decomposition 
changes  which  go  on.  Other  drugs  of  a  similar  class,  namely  salol,  creosote, 
resorcin,  naphthalin,  have  been  given  as  antiseptic  remedies  in  the  hopes  of 
checking  the  putrefactive  changes  in  the  bowel  and  preventing  the  formation 
of  toxic  products.  Salicylate  of  soda  has  been  used  by  A.  Jacobi,  of  New 
York,  and  also  by  Dr.  Emmet  Holt  ;  it  is  given  in  doses  of  one  to  three 
grains  every  two  hours  according  to  age.  Resorcin  may  be  given  in  \  to 
2  grain  doses  dissolved  in  water  every  two  hours.  But  these  antiseptic 
drugs  are  disappointing  in  the  worst  class  of  case.  Both  bismuth  in  the  form 
of  subnitrate  and  oxide  and  zinc  oxide  (F.  30  and  19)  are  usually  of  undoubted 
service.  Five-grain  doses  may  be  given  every  hour  to  an  infant  of  twelve 
months.  Opium,  during  the  first  twenty-four  or  forty-eight  hours,  is  useless  and 
harmful,  more  especially  when  there  is  imdigested  food  in  the  stools  and 
where  the  vomiting  is  persistent.  After  twenty-four  or  forty-eight  hours,  if  the 
stools  continue  small  and  numerous,  especially  if  they  approach  the 
dysenteric  type — the  large  bowel  being  chiefly  involved — this  drug  is  of 
much  value  in  soothing  the  patient  and  diminishing  irritability.  It  is  best 
given  by  enema.  The  advantage  of  this  method  is  that  it  is  slowly 
absorbed  and  its  topical  effects  are  useful  ;  one  or  two  enemata  of  laudanum 
during  the  twenty-four  hours  will  mostly  relieve  the  irritative  diarrhoea,  when 
accompanied  by  straining  and  colicky  pains,  without  the  necessity  of 
omitting  or  altering  the  medicine  given  by  the  mouth.  Two  to  five  drops  of 
laudanum  may  be  given  in  warm  decoction  of  starch  per  rectum  to  an  infant 
of  six  months  to  twelve  months,  the  effects  carefully  watched,  and  repeated 
in  the  course  of  six  to  twelve  hours  if  necessary  ;  ^V  of  a  grain  of  morphia 
may  be  given  subcutaneously  to  a  child  over  three  years  of  age  ;  or  Dover's 
powder  may  be  given  by  the  mouth,  ^  grain  every  three  or  four  hours,  or 
oftener  if  the  pain  and  griping  are  severe.  If  there  be  much  fever,  tepid 
sponging,  or  in  cases  of  greater  severity  sponging  with  ice-cold  water,  may 
be  practised. 

Stimulants  may  be  required  from  the  first,  but  it  is  wise  to  reserve  them 
for  a  later  stage,  especially  as  they  are  apt  to  give  rise  to  sickness.  Brandy, 
a  sound  port,  or  champagne,  is  the  form  of  alcoholic  stimulants  most  useful, 
and  they  are  usually  required  to  be  given  freely  in  the  later  stages  if  collapse 
is  threatened.  Ammonia,  camphor,  and  musk  are  valuable  remedies  if 
symptoms  of  collapse  have  made  their  appearance.  Camphor  may  be  given 
in  the  form  of  spirits  of  camphor,  three  or  four  drops  every  second  hour  ;  or 


Acute  Ilco-colitis  99 

musk.  (F.  29.)  Camphor  and  musk  are  not  agreeable  medicines  to  take, 
and  are  apt  to  cause  nausea. 

Irrigation  of  the  large  bowel  is  certainly  useful  in  severe  cases,  especially 
in  the  later  stages.  The  ulceration  and  inflammation  are  mostly  below  the 
caecum,  and  can  be  reached  by  fluid  injected  per  rectum.  A  soft  rubber 
catheter  is  passed  some  si\  or  eight  inches  into  the  rectum  and  attached  to 
a  Higginson's  ball  syringe.  Twenty  to  thirty  ounces  are  injected  so  as  to 
get  as  high  up  as  possible  ;  the  injection  may  be  continued,  allowing  the  fluid 
to  flow  back  by  the  side  of  the  catheter.  We  should  not  be  inclined  to 
irrigate  the  large  bowel  more  than  once  a  day  or  twice  at  the  most,  as  to 
disturb  the  child  too  much  is  prejudicial. 

Even  when  convalescence  is  established  great  care  must  be  exercised 
for  many  weeks  in  the  management  of  the  patient  ;  the  child  is  certain  to 
be  left  with  impaired  digestive  powers,  and  liable  to  gastric  or  intestinal 
disturbance.  A  severe  attack  will  often  affect  the  child's  health  and 
development  for  many  months,  so  that  it  is  late  in  talking  or  standing- 
alone,  and  at  1 8  months  or  two  years  of  age  resembles  a  child  of  1 2  months 
old  or  less.  Moreover,  the  diarrhoea  may  become  chronic  or  return  in  a 
subacute  form,  and  a  child  may  thus  be  lost  who  has  managed  to  struggle 
through  the  primary  attack.  The  diet  during  convalescence  requires  the 
most  extreme  care,  and  a  return  to  milk  diet  should  not  be  allowed  until 
there  is  evidence  of  much  improved  digestive  powers.  Broths  and  beef  tea 
made  with  barley  or  some  light  starchy  food,  meat  juice,  scraped  underdone 
chops,  whey,  and  Mellin's  Food,  may  be  given  in  moderation. 

The  mineral  acids,  pepsine  wine,  decoction  of  pomegranate  bark,  the 
vegetable  bitters  and  astringents,  will  be  useful  as  the  child  improves. 

Sianmary. — Place  the  child  in  the  coolest  room  of  the  house,  and  sponge 
frequently  if  there  is  much  fever. 

Stop  all  forms  of  milk  food,  giving  barley  or  arrowroot  water  with  white 
of  egg,  and  veal  broth  ;  if  there  is  much  vomiting  stop  all  food  for  some 
hours. 

Apply  hot  fomentations  or  counter-irritation  to  the  abdomen. 

Give  castor  oil  or  calomel  till  all  undigested  food  has  disappeared  from 
the  stools,  followed  by  salol,  zinc,  bismuth,  or  carbolic  acid.  Later,  if  there 
is  much  restlessness  or  colic,  give  opium  by  the  rectum.  In  severe  cases 
brandy  or  other  stimulant  will  be  required,  but  it  is  apt  to  cause  vomiting. 

In  infants  at  the  breast  lessen  the  quantity  of  milk  taken  and  give  some 
barley  water. 

Acute  Ileo-colltis.     Dysenteric  Diarrboea 

Diarrhoea  of  a  dysenteric  character  is  sometimes  secondary  to  acute 
catarrhal  diarrhoea,  or  it  may  follow  measles,  whooping  cough,  or  other 
zymotic  disease.  In  these  cases  it  is  mostly  chronic  or  at  the  most  subacute. 
There  is  straining  at  stool  :  the  evacuations  contain  much  mucus  and  are 
streaked  with  blood.  Prolapse  of  the  rectum  is  common.  In  some  cases, 
which  occur  almost  entirely  in  older  children,  ileo-colitis  is  an  exceedingly 
acute  and  fatal  disease.  Cases  of  this  description  have  been  recorded  by 
Henoch,  Goodhart,  and  Eustace  Smith.    The  onset  is  sudden,  with  vomiting, 

H  2 


lOO  Diseases  of  the  Digestive  System 

colic,  and  fever,  the  latter  usually  not  high  ;  there  is  much  straining  at  stool, 
followed  by  the  passage  first  of  fsecal  matters,  later  blood  and  mucus  only. 
There  is  mostly  some  abdominal  tenderness,  and  in  some  instances  a  purpuric 
or  petechial  rash  on  the  skin.  There  is  certain  to  be  great  depression  and 
rapidly  increasing  weakness.  There  is  often  delirium  at  night.  At  the 
autopsy  the  last  foot  or  so  of  the  ileum  is  found  to  be  involved,  while  the 
changes  are  more  marked  in  the  colon,  but  most  of  all  in  the  sigmoid  flexure 
and  rectum.  The  mucous  membrane  is  swollen  and  intensely  injected  with 
patches  of  thm  membranous  exudation,  or  if  the  child  has  lived  some  days 
there  is  ulceration  of  a  superficial  character.  The  etiology  of  these  cases  is 
obscure.  The  possibility  of  meat  poisoning  must  be  kept  in  mind.  They 
occur  in  the  hot  weather  of  summer,  but  their  occurrence  is  not  limited  to  this 
time.  One  of  our  cases  occurred  in  April,  at  the  height  of  an  epidemic  of 
influenza.     (See  below.) 

In  one  case  coming  under  our  notice  in  a  girl  of  twelve  years,  who  was 
admitted  to  hospital  under  the  care  of  our  colleague.  Dr.  Hutton,  the  attack 
commenced  with  vomiting  and  diarrhoea,  followed  by  delirium,  petechice  on 
the  skin,  and  bleeding  from  the  nose.  She  was  admitted  to  hospital  on  the 
sixth  day  of  her  illness  in  a  collapsed  condition,  with  a  pulse  of  190  and  a 
temperature  of  102°  F.  ;  she  passed  loose  stools  containing  some  hard  lumps 
with  blood  and  mucus  ;  later,  the  epistaxis  again  supervened,  the  tempera- 
ture rose  to  104°  F.,  and  she  died  exhausted  on  the  ninth  day  of  her  illness. 
The  post-morlem  showed  the  folds  of  the  mucous  membrane  of  the  colon  to 
be  of  an  ashy-grey  colour  with  well-defined  ulcers  varying  in  size  from  a  pin's 
head  to  half  an  inch  in  diameter  :  all  the  changes  were  more  marked  below 
the  sigmoid  flexure. 

In  another  case  of  a  somewhat  similar  nature  coming  under  our  care, 
the  symptoms  so  closely  resembled  those  of  an  invagination  of  the  intestines, 
that  an  exploratory  incision  was  made  into  the  abdominal  cavity.  Cases  of 
intussusception  are  not  infrequently  diagnosed  as  '  dysentery,'  but  it  is  rare 
for  the  opposite  mistake  to  be  made.     The  case  was  shortly  as  follows  : 

Acute  ileo-colitis — Death. — A  boy  of  nine  years  of  age  was  suddenly  seized  (April  22, 
1891)  with  pain  in  the  abdomen  whilst  at  school,  followed  by  the  passage  of  blood  and 
mucus  by  the  bowel ;  he  continued  in  this  way  during  the  succeeding  night.  He  was 
admitted  to  hospital  next  day,  and,  in  spite  of  fomentations  and  opium,  he  passed  twelve 
stools,  consisting  almost  entirely  of  blood  and  mucus.  Temperature  99-100°  F.  April 
24.— The  tenesmus  and  bloody  stools  continued,  in  spite  of  large  enemata  of  warm 
water  ;  the  latter  brought  away  a  small  quantity  of  faecal  matters .  No  tumour  could  be 
felt ;  the  abdomen  was  not  distended  nor  tender  to  the  touch.  Temperature  97-99 '6°  F. 
In  the  evening,  as  no  improvement  had  taken  place,  and  the  boy  seemed  rapidly  sinking, 
it  was  decided  to  explore  the  abdominal  cavity,  in  order  to  relieve  an  invagination  of  the 
bowel  if  present.  This  was  done  ;  but  no  invagination  was  found,  only  an  intensely  con- 
gested colon.  Death  followed  about  eight  hours  after.  At  \he.  post-mortem  the  stomach 
and  small  intestines,  to  within  twenty  inches  of  the  cascum,  were  found  normal ;  the  last 
foot  or  two  of  ileum  was  found  congested,  with  patches  of  thin  membranous  exudation. 
The  mucous  membrane  of  the  colon,  sigmoid  flexure,  and  rectum  was  intensely  injected, 
the  changes  in  the  lowest  parts  being  most  marked,  the  rectum  being  haemorrhagic.  There 
were  patches  of  thin  membranous  exudation,  but  no  ulcers. 

These  acute  cases  of  dysenteric  diarrhoea  appear  to  occur  in  children  of 
over  eight  or  nine  years  rather  than  in  younger  children. 


Meat  Poisoning  loi 

Diagnosis. — Tenesmus,  with  passage  of  blood  and  mucus  by  the  bowel, 
in  an  infant  under  a  year  old,  should  certainly  suggest  intussusception  rather 
than  ileo-colitis  ;  and  a  careful  exploration  of  the  rectum  and  palpation  of 
the  abdomen  should  certainly  be  made.  In  older  children  these  symptoms 
indicate  ileo-colitis  rather  than  invagination  ;  fever,  delirium,  vomiting,  also 
point  the  same  way. 

Treatment. — In  acute  ileo-colitis  only  the  blandest  food  should  be  given, 
such  as  arrowroot,  veal  broth,  or  white  of  ^"gg  mixture,  and  if  there  is  vomit- 
ing, the  less  food  given  the  better.  Hot  fomentations  containing  opium 
should  be  applied  to  the  abdomen,  and  every  effort  made  to  allay  the  inflam- 
matory condition  of  the  colon  by  small  starch  and  opium  enemata.  Five  to  six 
ounces  of  warm  starch  mucilage  and  boracic  acid  with  lo  minims  of  laudanum 
may  be  administered  to  a  child  of  ten  years.  Anything  that  can  possibly 
irritate,  such  as  purgatives  or  indigestible  food,  must  be  avoided,  as  likely  to 
increase  the  peristalsis  and  tenesmus.  Stimulants  are  certain  to  be  required 
sooner  or  later.  In  mild  or  chronic  cases  irrigation  of  the  bowel  is  often  of 
the  greatest  service.  Thin  starchy  mucilage  may  be  used  with  lac  bismuthi, 
and  the  amount  employed  should  be  sufficiently  large  to  reach  the  caecum. 
Laxatives,  as  rhubarb  and  soda  or  castor-oil  emulsion,  are  also  useful  in  the 
early  stages.  Great  care  must  be  taken  in  the  diet,  and  all  rich  foods 
avoided. 

I^eat   Poisoning-.      Infection  -with   Gaertner's   Bacillus 

Under  this  head  we  refer  to  the  acute  gastro-intestinal  disturbance  which 
follows  the  ingestion  of  some  form  of  animal  food  which  is  infected  with  the 
Bacillus  enteritidis,  first  described  by  Gaertner.  Besides  this  bacillus  and  its 
varieties  other  organisms  have  been  described  (B.  botulinus),  but  Gaertner's 
is  by  far  the  most  common.  The  diseased  animal  is  usually  either  the  cow, 
calf,  or  pig,  and  the  infection  of  human  beings  is  the  result  of  eating  imperfectly 
cooked  beef,  veal,  veal  or  pork  pies,  sausages,  and  in  some  cases  raw  milk. 
No  cases  appear  to  have  occurred  after  using  mutton.  An  exposure  of  one 
minute  to  a  temperature  of  158°  F.  is  sufficient  to  destroy  Gaertner's 
bacillus,  and  the  toxines  associated  appear  to  be  destroyed  by  a  boiling 
temperature  (H.  E.  Durham). 

The  infection  is  due  to  the  ingestion  of  the  bacillus  itself  and  the  consequent 
development  of  toxines  in  the  system,  and  not  to  the  ingestion  of  the  toxines 
themselves  :  in  all  fatal  cases  the  bacilli  have  been  found  (H.  E.  Durham). 
The  animals  appear  to  have  suffered  from  septicaemia,  diarrhoea,  and  localised 
suppurations. 

The  symptoms  set  in  within  a  few  hours,  and  include  rigors,  vomiting, 
diarrhoea,  with  excessive  griping  and  sometimes  blood  in  the  stools,  fever 
often  high,  followed  in  severe  cases  by  subnormal  temperature,  and  marked 
collapse  with  weak  irregular  action  of  the  heart.  Herpes  occurs  in  some 
cases. 

In  an  epidemic  which  we  had  an  opportunity  of  observing,  it  was  the  milk 
which  was  at  fault.  Upwards  of  160  individuals  were  attacked  within  a  few 
hours  of  one  another,  in  several  families  as  many  as  twelve,  the  children 
suffering  the  most.     All  the  families  were  supolied  with  milk  from  the  same 


I02  Diseases  of  the  Digestive  System 

farm.  The  outbreak  was  investigated  by  Dr.  Niven,  who  traced  the  out- 
break to  a  cow  suffering  from  inflammation  of  the  udder. 

The  diagnosis  of  the  cause  in  such  cases  is-  aided  by  the  possibility  of 
tracing  the  cause  of  the  illness  to  some  form  of  food  such  as  veal  or  pork 
pies,  sausages,  milk,  &c.  It  must  be  borne  in  mind  that  the  meat  or  milk  is 
not  obviously  bad  or  stale,  and  only  a  bacterial  examination  by  an  expert  will 
prove  it  to  be  at  fault.  Blood  should  be  taken  from  the  individuals  attacked 
for  '  serum  reactions,'  and  forwarded  to  an  expert.  It  must  be  remembered 
that  influenza  may  sometimes  give  rise  to  a  febrile  gastro-intestinal  disturbance, 
but  the  fact  that  many  people  are  attacked  within  a  few  hours  of  one  another, 
and  then  no  others  are  attacked,  would  arouse  the  suspicion  of  meat  or  milk 
poisoning. 

The  treatment  is  practically  the  same  as  already  given  under  Gastro- 
intestinal Infection.  The  intense  griping  may  require  full  doses  of  opium 
for  its  relief 


lO- 


CHAPTER   VI 

DISEASES   OF   THE   DIGESTIVE   SYSTEM — {continued) 

Chronic  Gastro-intestlnal  Catarrh.     Gastro-intestinal  Atrophy 

In  some  cases  a  gastric  catarrh  exists  with  but  Httle  evidence  of  the  intes- 
tines being  in  any  way  affected,  and  in  other  cases  the  intestines  may  be  the 
only  part  of  the  ahmentary  canal  ^\•hich  appears  to  suffer  ;  but  in  perhaps 
the  majority  of  cases,  especially  in  infants  and  small  children,  there  is  no 
sharply  defined  limitation  between  the  two,  the  whole  of  the  alimentary  canal 
appearing  to  be  involved. 

The  terms  chronic  vomiting^,  chronic  diarrhoaa,  simple  atrophy, 
marasmus,  malnutrition,  athrepsia,  are  sometimes  applied,  according  to 
the  most  prominent  symptom  which  is  present  ;  thus,  chronic  vomiting  is 
the  most  marked  and  striking  symptom  which  may  be  present  in  catarrh  of 
the  stomach  ;  diarrhoea  is  mostly  present,  or  at  least  more  or  less  looseness 
of  the  bowels,  in  the  early  stages  of  an  intestinal  catarrh,  though  the  latter  may 
exist  without  any  marked  diarrhoea,  or  in  the  later  stages  there  may  be  con- 
stipation. If  the  only  marked  symptoms  are  dyspepsia  and  Avasting,  then 
the  term  simple  atrophy  has  been  applied.  In  all  these  conditions,  w^hile 
the  symptoms  may  differ,  the  anatomical  groundwork  is  the  same — namely, 
a  chronic  gastro-intestinal  catarrh,  which  in  later  stages  passes  into  a  gastro- 
intestinal atrophy. 

Thus,  an  infant  soon  after  birth,  or  perhaps  when  a  few  months  old, 
suffers  from  repeated  and  frequent  vomiting,  or  it  suffers  from  diarrhoea,  or 
if  these  are  absent  there  are  other  chronic  dyspeptic  troubles,  such  as  flatu- 
lence and  colic  ;  it  fails  to  thrive  and  gradually  wastes,  and  after  a  more  or 
less  protracted  illness,  during  which  the  wasting  becomes  extreme,  it  dies 
exhausted  or  is  carried  off  by  some  intercurrent  disease.  In  some  cases  the 
course  is  very  short,  perhaps  only  a  few  weeks,  but  in  the  majority  the 
disease  is  chronic  and  the  infant  lives  for  months,  suffering  constantly  from 
dyspepsia,  unable  to  digest  its  food,  and  wasting  to  a  mere  skeleton.  The 
less  severe  cases,  especially  if  they  come  under  treatment,  gradually  improve, 
9.nd  after  months  of  the  most  careful  feeding  and  nursing  completely  recover, 
though  such  cases  usually  become  rickety  or  are  otherwise  weakly.  Recovery 
is  only  possible  during  the  earlier  stages  ;  if  the  catarrhal  stage  has  passed 
on  into  one  in  which  there  is  advanced  atroph)^  of  the  mucous  membrane 
of  the  stomach  and  intestines  with  the  secreting  glands,  recovery  is  hardly 
possible. 


104  Diseases  of  the  Digestive  System 

Experimental  research  has  shown  that  in  these  cases  there  is  a  diminution 
in  the  amount  of  hydrochloric  acid  and  pepsin  secreted,  while  there  is  an 
excessive  formation  of  mucus,  lactic,  acetic,  and  butyric  acids.  Much  gas  is 
given  off  from  the  decomposing  food. 

This  gastro-intestinal  atrophy  rarely  occurs  in  children  over  i8  months  of 
age,  and  indeed  is  most  common  in  infants  under  6  months.  Older  children 
suffer  from  chronic  intestinal  catarrh,  which  rarely  goes  on  to  atrophy,  though 
it  is  frequently  the  precursor  of  tuberculosis  of  the  mesenteric  glands. 

In  the  majority  of  cases,  chronic  gastro-intestinal  catarrh  is  the  j-esult  of 
improper  feeding  and  unfavourable  life  conditions.  Infants  who  come  of  a 
healthy  stock  and  are  nursed  at  the  breast  of  healthy  mothers  rarely,  if  ever, 
suffer  from  it.  It  is  the  infants  who  are  fed  from  the  first  on  cow's  milk  or 
the  various  forms  of  starchy  foods  that  chiefly  suffer.  The  infant  may  go 
on  fairly  well  for  the  first  few  weeks  or  more,  suffering  more  or  less  from 
dyspepsia  ;  then  comes  an  attack  of  diarrhoea  or  vomiting,  and  forthwith  it 
begins  to  go  downhill ;  no  food  seems  to  suit  it,  however  often  changed,  and 
it  never  recovers  its  digestive  powers,  which  appear  to  have  been  hopelessly 
damaged.  Some  infants  appear  to  get  on  fairly  well  till  they  suffer  from  an 
attack  of  broncho-pneumonia,  or  measles,  or  whooping  cough,  which  they 
survive  only  to  begin  gradually  to  waste.  In  some  few  instances,  more 
especially  in  dispensary  practice,  atrophic  infants  may  be  seen  of  a  few 
months  old,  who  have  been,  according  to  their  mothers'  accounts,  entirely 
breast-fed.  In  these  cases  the  infants  have  been  congenitally  weak  or  pre- 
mature, and  probably  the  mother's  milk  has  been  deficient  in  quality  and 
quantity,  and  they  have  been  exposed  to  all  the  insanitary  conditions  which 
prevail  in  the  crowded  dwellings  of  the  poorest  and  most  ignorant  of  our 
citizens. 

Symptoms. — Infants. — The  history  which  is  generally  obtained  from  such 
cases  is  that  they  were  suckled  for  a  few  weeks  or  months  after  birth,  then 
the  mother  had  to  go  to  work  or  her  milk  failed,  and  the  infant  was  made 
over  to  a  friend  or  hireling  to  be  artificially  fed,  and  from  this  time  it  began 
to  waste.  On  cross-questioning  the  mother  or  caretaker,  it  is  found  that  it  has 
been  fed  on  sopped  bread  or  biscuits,  because  cow's  milk  did  not  appear  to 
satisfy  it,  or  it  vomited  the  milk  curdled,  and  it  has  constantly  suffered  from 
colic,  vomiting,  or  more  commonly  diarrhoea.  On  the  other  hand,  there  is 
sometimes  constipation,  but  this  usually  has  been  preceded  by  diarrhcea  ; 
the  diarrhceal  symptoms  being  most  marked  in  those  suffering  during  the 
summer  months.  If  the  symptoms  be  analysed,  three  stages  in  the  course  of 
the  disease  may  be  recognised  as  first  clearly  pointed  out  and  emphasised  by 
.  Parrot,  whose  description  of  these  cases  under  the  name  of  athrepsia  leaves 
nothing  to  be  desired.  The  early  symptoms  or  first  stage  are  those  of  a 
simple  gastric  or  intestinal  catarrh,  in  the  second  the  progressive  wasting  be- 
comes the  prominent  phenomenon,  and  in  the  last  stage  the  infant  passes  into 
an  exhausted  condition  in  Avhich  cerebral  symptoms  make  their  appearance. 
First  stage.  The  infant  suffers  from  a  simple  diarrhoea  or  looseness  of  the 
bowels  ;  the  stools,  instead  of  being  bright  yellow  and  homogeneous,  are 
liquid,  curdy,  and  often  green  in  colour,  or  contain  an  excess  of  mucus  ; 
sometimes  they  consist  almost  entirely  of  stinking  decomposing  milk;  the 
abdomen  is  distended  with  gas  and  remains  constantly  in  this  condition,  the 


Chronic  Intestinal  Catarrh  105 

tongue  is  coated,  and  patches  of  aphthous  stomatitis  appear  in  the  mouth. 
The  infant  is  restless,  constantly  whining,  and  will  not  sleep  at  night.  Frequent 
vomiting  may  be  a  prominent  symptom,  the  milk  being  returned  curdled. 
The  tissues  become  llabby,  and  then  wasting  commences.  In  the  second 
stage  all  the  symptoms  are  intensified  and  the  characteristic  wasting  becomes 
manifest.  The  stools  for  the  most  part  are  loose  and  frequent,  and  consist 
of  undigested  food,  being  often  pale  and  putty-like,  with  a  peculiar  odour  ; 
at  other  times  they  are  of  a  dark  brown  colour  from  the  presence  of  altered 
bile.  The  infant  is  mostly  voracious,  liquid  food  does  not  appear  to  satisfy 
it,  and  by  the  mistaken  kindness  of  its  friends  it  is  fed  with  sopped  bread 
or  some  thick  food,  a  diet  which  has  the  great  merit  in  their  eyes  of  keeping 
it  quiet  for  a  longer  time  than  liquid  food  or  chluted  milk  ;  at  times  it  cries 
incessantly,  hardly  ever  appearing  to  sleep  or  only  dozing  for  a  short  time 
unless  under  the  influence  of  a  '  soothing  syrup '  supplied  by  its  nurse.  The 
mouth  becomes  the  seat  of  parasitic  stomatitis,  the  skin  is  harsh  and  dry, 
small  boils  or  a  lichenous  rash  make  their  appearance,  the  buttocks  and 
genitals  are  raw  and  excoriated.  Its  temperature  is  below  normal,  the  feet 
and  hands  are  congested,  the  face  has  a  pallid  earthy  tint,  and  a  sickly  lactic 
acid  smell  is  given  out  from  the  body,  especially  the  abdomen.  The  wasting 
is  extreme,  the  face  being  shrivelled,  the  skin  wrinkled  and  hanging  in  folds 
about  the  thighs  and  arms.  In  the  tJiird  stage  the  infant  passes  into  a 
moribund  state  ;  it  is  too  feeble  to  cry  loudly,  it  is  heavy  and  drowsy, 
taking  little  notice  of  anything.  It  becomes  more  and  more  somnolent,  and 
death  ensues,  probably  preceded  by  muscular  twitchings,  strabismus,  or 
general  convulsions. 

If  we  analyse  the  principal  symptoms  of  the  disease,  we  shall  find  that 
sometimes  one  symptom,  as  diarrhoea,  sometimes  another,  as  vomiting,  is  the 
most  prominent.  In  the  majority  of  the  cases  there  is  more  or  less  diarrhoea 
throughout  the  whole  course,  so  that  such  cases  would  come  under  the  cate- 
gory of  chronic  diarrhoea,  or  this  chronic  condition  may  alternate  with  the 
acuter  forms.  The  stools  at  first  are  yellow,  liquid  and  frothy,  with  fiocculi 
of  semi-digested  curd ;  later  they  become  green,  the  acid  contents  of  the 
intestines  acting  on  the  bile  pigments  ;  when  the  diarrhoea  has  become  chronic 
the  stools  are  either  liquid  and  of  a  dirty  brown  colour,  or  more  often, 
especiahy  if  milk  is  being  taken,  they  are  white  and  semi-liquid,  the  bile 
pigment  having  disappeared,  and  they  consist  of  decomposing  foul-smeUing 
curd  and  mucus.  Sometimes  the  stools  consist  almost  entirely  of  mucus, 
the  mucous  membrane  both  of  the  small  and  large  intestine  secreting  large 
quantities  ;  the  child  is  constantly  passing  stools  of  mucus  and  undigested 
food. 

In  some  cases  chronic  vomiting'  is  the  most  troublesome  symptom, 
there  being  no  diarrhoea  but  sometimes  constipation.  Cases  of  chronic 
vomiting  with  the  consequent  malnutrition  are  at  times  most  difficult  to  deal 
with.  So  great  is  the  irritability  of  the  stomach  that  everything  is  rejected, 
either  immediately  after  being  taken,  or  after  the  lapse  of  perhaps  half  an 
hour.  Diluted  milk,  peptonised  preparations,  meat  juice,  cream,  and  a  variety 
of  patent  foods  are  tried  one  after  another,  separately  or  mixed  ;  each  change 
only  ends  in  disappointment,  the  infant  becoming  more  and  more  wasted. 
Under  such  circumstances  among  the  poorer  classes   the  infant   is   given 


io6  Diseases  of  the  Digestive  System 

some  thick  food,  as  sopped  bread  or  corn  flour.  Vomiting  in  many  cases 
appears  to  be  the  resuk  of  the  rapidity  with  which  cow's  milk  is  coagulated 
in  the  infant's  stomach  and  of  the  hard  lumps  of  curd  which  are  thrown  down, 
this  occurring  even  where  the  milk  is  reduced  to  one  part  of  milk  to  five  of 
water.  In  other  instances  it  appears  to  be  due  to  the  rapid  changes  occur- 
ring in  the  sugar  of  milk,  lactic  acid  being  formed ;  the  contents  of  the 
stomach  are  rejected,  having  a  strong  smell  of  sour  and  decomposing  milk. 
In  the  catarrhal  condition  of  the  mucous  membrane  of  the  stomach  much 
mucus  is  formed,  while  the  gastric  juice  is  weak,  but  its  curdling"  power 
undiminished.  Many  such  cases  go  from  bad  to  worse,  no  food  appearing  to 
agree,  all  forms  coming  up  alike. 

As  the  child  wastes  the  skin  becomes  rough  and  harsh  and  hangs  in  folds 
upon  the  limbs  and  trunk,  and  very  frequently,  as  the  aneemia  increases,  the 
face,  hands,  and  feet  become  oedematous.  This  oedema  is  due  to  ansemia 
rather  than  to  any  kidney  complication.  An  erythematous  rash  is  apt 
to  make  its  appearance  about  the  anus  in  those  cases  where  there  is  much 
diarrhoea,  and  spread  over  the  perineum  and  thighs. 

It  must  not  be  forgotten,  in  a  case  of  constant  vomiting,  that  it  may 
be  due  to  cerebral  disease  or  some  congenital  defect.  The  prognosis  in 
chronic  vomiting  is  unfavourable  if  it  commences  in  an  artificially  reared 
infant,  and  becomes  thoroughly  established,  and  is  associated  with  progres- 
sive wasting. 

Complications. — Broncho-pneumonia  is  very  common.  Tuberculosis  of 
the  mesenteric  or  mediastinal  glands  may  occur,  or  there  may  be  a  more 
general  distribution  of  tubercle  throughout  the  body.  It  must  be  borne  in 
mind  that  it  is  only  in  the  more  severe  and  neglected  cases  that  intestinal 
catarrh  passes  on  into  atrophy  ;  in  the  majority  of  cases  the  course  of  the 
disease  is  intermittent,  sometimes  better,  at  other  times  worse,  and  as  the 
child  grows  older  the  symptoms  of  rickets  become  grafted  on  to  those  of  a 
chronic  catarrh  of  the  bowels. 

Older  Children. — A  chronic  intestinal  catarrh  is  not  so  serious  a  disease 
in  children  over  two  years  of  age  as  in  infants,  as  it  is  rarely  followed  by  an 
atrophic  condition  of  the  glandular  apparatus  of  the  stomach  and  intestines, 
but  takes  rather  the  form  of  habitual  indigestion  than  anything  else.  It  is, 
however,  apt  to  be  exceedingly  chronic  in  its  course  and  to  be  followed  by 
various  evil  consequences,  the  most  serious  of  which  is  tuberculosis  of  the 
lymphatic  glands,  or  there  is  a  constant  state  of  health  below  par,  which  in 
itself  is  a  source  of  danger.  Chronic  catarrhal  affections  of  mucous  mem- 
branes, either  of  the  nose,  mouth,  respiratory  tract,  or  intestines,  are  ex- 
ceedingly apt  to  be  followed  by  swelling  and  caseous  degeneration  of  the 
lymphatic  glands,  with  which  the  mucous  membrane  is  connected.  The 
intestinal  lesion  finds  its  origin  for  the  most  part  in  unsuitable  food  ;  the 
mucous  membrane  of  the  stomach  and  bowels  is  kept  in  a  constant  state  of 
irritation  by  food  which  is  too  great  in  quantity  or  of  too  indigestible 
character.  Weakly  children  are  especiall)^  apt  to  suffer,  particularly  those 
who  are  brought  up  in  our  large  cities  and  whose  time  is  spent  either  indoors 
or  playing  in  the  street.  Children  who  suffer  habitually  from  rhinitis, 
chronic  tonsillitis,  or  chronic  disease  of  the  strumous  type,  are  the  chief 
sufferers   from   chronic   gastro-intestinal   catarrh.     It   is   very   common   in 


Clirofiic  Intestinal  Catarrh  107 

rickety  children.      l>oth  the  children  of  the  well-to-do  and  of  the  po(jr  classes 
suffer. 

Symptoms.— T\\&x&  is  habitual  indigestion  with  perverted  appetite,  the 
child  refusing  its  bread  and  milk  and  craving  for  'tasty 'bits  from  its  parents' 
table,  or  altogether  refusing  its  meals  unless  its  food  is  highly  seasoned  ;  at 
other  times  the  appetite  is  excessive.  The  abdomen  is  invariably  rounded 
from  the  constant  distension  of  the  stomach  and  intestines  with  gas  given  off 
from  the  decomposing  half-digested  food.  This  distension  is  very  frequently 
accompanied  by  more  or  less  pain.  The  face  is  generally  pale  with 
dark  areohe  around  the  eyes,  fat  is  absorbed  as  the  disease  progresses,  the 
muscles  become  flabby,  and  the  emaciation  of  the  child  contrasts  markedly 
with  its  large  tumid  abdomen.  Such  children  have  usually  coated  tongues, 
at  other  times  the  tongue  is  red  and  glazed,  showing  the  enlarged  fungiform 
papilla;  more  distinctly  than  usual  and  resembling  the  '  strawberry  tongue ' 
of  scarlet  fever.  Sometimes  the  surface  has  a  worm-eaten  appearance, 
being  coated  with  a  thick  fur  except  in  irregular  sinuous  patches  where  the 
surface  is  red  and  glazed.  The  bowels  are  generally  confined,  the  stools  being 
frequently  pasty  with  much  mucus  ;  there  are  apt  to  be  intercurrent  attacks 
of  vomiting  and  diarrhoea.  There  is  very  frequently  more  or  less  feverish- 
ness  at  night,  especially  in  the  subacute  cases.  Headaches  are  common, 
there  is  often  restlessness  at  night,  grinding  of  teeth,  and  night  terrors.  Some- 
times when  the  disease  is  subacute,  and  there  is  some  feverishness  towards 
evening,  the  symptoms  resemble  mild  typhoid  fever  and  constitute  what  at 
one  time  was  called  'infantile  intermittent  fever.'  It  is  important  to  bear  in 
mind  that  subacute  intestinal  catarrh  may  be  present  with  an  evening  ex- 
acerbation of  temperature  as  the  principal  symptom  and  with  no  vomiting 
or  diarrhoea.  An  intermittent  fever  during  early  childhood  with  no  pulmo- 
nary symptoms  is  probably,  if  typhoid  can  be  excluded,  due  to  an  intestinal 
catarrh.  It  will  not  fail  to  be  noticed  that  diarrhoea  is  a  prominent  symptom 
in  the  majority  of  cases  of  infants  suffering  from  chronic  intestinal  catarrh, 
while  in  older  children  not  only  is  the  diarrhoea  not  present,  but  there  is 
usually  constipation.  The  explanation  of  this  is  perhaps  not  very  clear,  but 
it  must  be  borne  in  mind  that  those  cases  where  diarrhcea  is  present  and 
excessive  are  more  acute  in  character  and  run  a  more  rapid  course  than  those 
where  the  bowels  are  less  irritable  ;  there  is  also  more  likely  to  be  diarrhoea  in 
the  early  stages  where  the  mucous  membrane  is  congested,  than  in  the  later 
stages  where  the  bowels  have  become  more  tolerant  of  irritation  and  the 
muscular  walls  wasted  through  long  illness. 

In  some  cases  of  intestinal  catarrh,  more  particularly  when  it  complicates 
or  follows  whooping  cough  or  measles,  there  is  an  excessive  formation  of  mucus 
from  the  intestinal  walls,  especially  the  large  bowel  ;  Dr.  Eustace  Smith 
has  called  special  attention  to  these  cases  under  the  name  of  '  mucous 
disease.'  The  bowels  are  usually  loose,  the  stools  consisting  largely  of 
mucus,  or  an  aperient  may  bring  away  large  cjuantities  of  mucus.  In  the 
worst  cases,  when  this  form  of  disease  complicates  whooping  cough,  the 
prognosis  is  bad. 

Diagnosis. — The  disease  most  likely  to  be  confounded  with  chronic  intes- 
tinal catarrh  is  tuberculosis  of  the  mesenteric  glands,  or  the  early  stages  of 
tubercular  meningitis.     During  the  first  three  or  four  years  of  life,  it  happens 


io8  Diseases  of  the  Digestive  Sy stein 

very  frequently  that  infants  or  young  children  are  thought  to  have  '  consump- 
tion of  the  bowels,'  because  they  have  capricious  appetites,  '  pot-bellies,'  and 
have  lost  much  flesh,  when  in  reality  they  are  suffering  from  a  chronic  intes- 
tinal catarrh.  That  the  diagnosis  is  often  difficult  is  only  what  is  to  be  ex- 
pected when  it  is  remembered  that  an  intestinal  catarrh  of  more  or  less  severity 
is  the  exciting  cause  of  mesenteric  tuberculosis  ;  and  in  an  advanced  case,  it 
may  be  quite  impossible  to  say  if  a  tuberculosis  of  the  glands  has  supervened. 
Mesenteric  disease  is,  however,  much  less  common  than  simple  intestinal 
catarrh,  and  is  infinitely  less  so  during  the  first  six  months  of  life  than  gastro- 
intestinal atrophy.  Any  evidence  of  tubercle  in  the  lungs,  or  enlai'ged  veins 
on  the  surface  of  the  abdomen,  or  the  detection  of  rounded  masses  by  palpa- 
tion in  the  abdomen,  would  favour  a  diagnosis  of  tubercular  disease.  In 
older  children  the  fact  that  those  suffering  from  intestinal  catarrh  grind  the 
teeth,  are  restless  at  night,  are  subject  to  night  terrors  and  headaches,  is 
sufficient  for  most  parents  to  become  alarmed,  fearing  that  the  child  is  com- 
mencing with  tubercular  meningitis. 

Morbid  Anatomy. — Chronic  Gastro-intesiinal  Catarrh. — In  the  early 
stages  there  is  swelling,  and  injection  of  the  mucous  membrane  of  the 
stomach,  and  small  and  large  intestine.  The  surface  is  grey,  streaked  with 
red,  and  there  is  an  excess  of  mucus  :  the  changes  are  usually  most 
marked  in  the  ileum  and  colon,  especialty  about  the  sigmoid  flexure  ;  in 
these  places  the  solitary  glands  are  enlarged,  the  mucous  membrane  is 
raised  in  folds,  and  often  much  injected,  and  follicular  ulceration  may  be 
present.  The  microscopical  appearances  somewhat  resemble  those  already 
described  in  acute  catarrh.  The  surface  of  the  mucous  membrane  of  the 
stomach  is  covered  witn  masses  of  leucocytes  and  micrococci  embedded, in 
mucus.  The  capillaries  are  everywhere  distended,  the  gastric  glands  are 
separated  from  one  another  by  columns  of  leucocytes  effused  between  them, 
the  whole  mucous  membrane  is  swollen,  and  the  muscular  layer  thickened. 

Similar  changes  are  seen  in  the  intestines,  leucocytes  are  present  in  large 
numbers  in  the  submucosa  and  between  Lieberkuhn's  glands  ;  the  latter  are 
compressed  and  finally  disappear,  so  that  in  places  only  masses  of  round  cells 
are  seen  taking  the  place  of  the  glands.  A  stage  of  atrophy  succeeds  that  of 
chronic  catarrh,  and  the  appearances  presented  are  those  of  a  wasting  of  the 
mucous  membrane,  and  a  destruction  of  the  secreting  glands.  The  chronic 
swelling  of  the  mucosa,  and  infiltration  with  leucocytes,  have  led  to  a  wasting 
and  cicatrisation  of  the  tubular  glands  ;  but  death  usually  takes  place  before 
this  stage  is  reached. 

In  gastro-intestifiat  atrophy  the  stomach  and  intestines  are  distended 
with  gas,  the  former  is  frequently  dilated,  the  mucous  membrane  is  every- 
where pale,  the  intestines  are  thin  and  translucent.  This  is  especially 
marked  in  the  more  advanced  cases,  the  intestinal  walls  are  exceedingly 
thin,  the  solitary  glands  and  Peyer's  patches  are  wasted  and  have  almost 
disappeared,  with  perhaps  brownish  spots  or  streaks  where  minute  hsemor- 
rhages  have  taken  place.  These  appearances  will  be  varied  with  those  of 
chronic  catarrh  according  to  the  amount  of  atrophy  that  has  taken  place. 
The  microscopical  appearances  show  the  mucous  membrane  of  the  stomach 
to  have  undergone  wasting,  being  reduced  to  perhaps  one-quarter  its  normal 
thickness.     The  gastric  glands  in  places  have  completely  disappeared,  in 


Chronic  Intestinal  Catarrh  109 

other  places  they  are  compressed  and  partly  destroyed  by  round  cells  and 
young  connective-tissue  fibres.  In  the  small  intestines  the  ajDpearances 
will  be  those  of  chronic  catarrh,  or  these  with  the  addition  of  destruction  of 
the  glandular  apparatus.  The  tubular  glands  in  places  are  atrophied  or 
are  compressed  or  dilated  by  a  connective-tissue  growth,  the  villi  have 
completely  disappeared,  or  only  their  remains  are  present,  the  solitary  glands 
are  atrophied  or  have  disappeared.  Similar  changes  may  be  found  in  the 
colon.  Parrot  has  described  various  other  lesions  in  the  alimentary  canal 
of  infants  dying  within  a  few  weeks  of  their  birth  ;  such  as  a  spread  of  the 
parasitic  growth  from  the  mouth  to  the  stomach  and  intestine,  usually  the 
CKcum.  The  same  author  has  found  minute  circular  ulcers  in  the  stomach, 
from  which  haemorrhage  has  taken  place,  less  often  larger  and  irregularly 
shaped  ones  ;  he  has  also  seen  the  mucous  membrane  of  the  stomach  to  be 
the  seat  of  a  diphtheroid  exudation.  In  the  later  stages,  when  the  blood  is 
profoundly  altered,  thrombosis  of  the  renal  veins,  pulmonary  veins,  or 
sinuses  of  the  brain  may  take  place.  Fatty  degeneration  {steatose  of  Parrot), 
softening,  or  meningeal  hcemorrhage,  may  take  place  in  the  brain.  The 
kidney  may  be  the  seat  of  uric  acid  infarcts. 

Treatment. — The  treatment  of  chronic  gastro-intestinal  catarrh  in  infants 
consists  principally  in  careful  feeding  ;  the  blandest  and  least  irritating  forms 
of  food  must  be  selected,  while  frequent  weighings  of  the  infant  should  be 
resorted  to  in  order  to  ascertain  if  any  progress  is  being  made.  In  infants 
under  four  months  a  wet  nurse  should  be  obtained  if  possible.  Where 
there  is  much  diarrhoea,  milk  must  be  used  sparingly  or  altogether  omitted 
for  a  while,  as  the  hard  curds  formed  in  the  stomach  are  beyond  the  digestive 
powers  of  the  weakened  stomach  and  intestines.  Small  quantities  of  whey 
and  barley  water,  with  the  addition  of  the  juice  of  an  underdone  chop,  may 
be  given  at  short  intervals  during  both  day  and  night.  Improvement  having 
taken  place  as  regards  the  diarrhcea,  milk  in  some  form  or  other  must  be 
given.  Milk  modified  so  as  to  reduce  the  proteids  to  -5  or  75  per  cent., 
with  2  per  cent,  fat  and  5  per  cent,  sugar,  may  be  given,  or  one  of  the  forms 
of  desiccated  milk  already  referred  to.  The  amount  of  proteids  should  be 
gradually  increased,  if  they  appear  to  be  digested  well.  It  may  be  worth 
trying  milk  which  has  been  predigested  by  pancreatine.  Every  care  must 
be  taken  that  the  feeding  bottle  is  clean,  and  the  food  prepared  with  the 
most  scrupulous  care.  Whenever  the  weather  permits,  the  infant  must  be 
taken  into  the  open  air  as  much  as  possible.  The  medicines  given  must  be 
selected  according  to  the  most  prominent  symptoms.  If  the  stools  are 
loose,  contain  much  mucus  and  curd,  and  are  foul  or  stinking,  small  doses 
of  castor-oil  emulsion  or  calomel  should  be  given,  to  be  followed  by  bismuth 
and  small  doses  of  opium.  If  the  stools  are  dark  brown  or  yellow  and  very 
liquid,  astringents  in  the  form  of  extract  of  logwood,  catechu,  or  pomegranate 
will  be  of  most  service,  especially  if  small  doses  of  opium  are  given  by  the 
bowel.  (F.  20,  32.)  If  the  diarrhoea  approach  the  dysenteric  type,  much 
mucus  and  blood  being  passed  with  straining  and  forcing  down,  irrigating 
the  bowel  with  a  warm  decoction  of  starch  and  boric  acid  (20  to  30  oz.)  or 
small  enemata  of  starch  and  opium  may  be  used  with  advantage. 

The  treatment  of  chronic  gastric  catarrh  in  infants  when  it  has  become 
confirmed  is  very  often  extremely  discouraging.     In  the  milder  forms  of 


no  Diseases  of  the  Digestive  System 

vomiting  the  importance  of  modifying  the  milk  so  as  to  reduce  the  quantity 
of  curd,  or  of  peptonising  the  milk  to  gain  the  same  end,  must  be  insisted 
upon  ;  milk  foods  containing  much  fat  are  usually  badly  borne.  It  is  also 
of  much  importance  not  to  give  food  too  frequently,  but  to  give  the  stomach 
a  complete  rest  for  several  hours.  In  severer  cases  in  which  milk  or  whey, 
in  whatever  form  it  is  given,  returns  sour  and  curdled  in  a  few  minutes, 
other  food  must  be  substituted  at  least  for  a  time.  In  such  cases  Mellin's 
Food,  either  made  with  water  or  weak  veal  broth  (half  a  pound  to  the  pint), 
may  be  given  ;  the  bottle  being  discontinued  and  the  infant  fed  with  a 
spoon.  Instead  of  veal  broth,  raw  meat  juice  or  '  liquid  meat '  may  be  used. 
After  a  few  days,  milk  may  be  again  tried,  or  small  quantities  of  cream  may 
be  added  to  the  Mellin's  Food  in  lieu  of  the  meat  juice.  In  this  acid  con- 
dition of  stomach  small  doses  of  sodii  bicarb,  and  pepsine  are  often  very 
useful.     (F.  34,  35.) 

In  older  children  careful  dieting  is  of  the  utmost  importance,  and  the 
first  difficulty  encountered  will  probably  be  that  the  child  has  been  over- 
indulged and  so  spoilt  by  its  parents  that  it  is  difficult  to  get  it  to  take  a 
carefully  selected  and  restricted  diet.  In  arranging  a  diet  it  must  be  borne 
in  mind  that  the  child  should  take  only  such  quantities  as  the  impaired  state 
of  the  digestive  juices  can  deal  with,  any  excess  being  liable  to  undergo  decom- 
position in  the  intestines,  and  give  rise  to  flatulence  and  other  troubles.  It 
is  also  most  important  to  give  the  stomach  a  complete  rest  during  the 
intervals  between  meals  ;  sweet  biscuits  taken  during  the  morning  or  a  run 
on  the  kitchen  at  frequent  intervals  during  the  day  are  fruitful  sources  of 
chronic  indigestion,  and  the  plainest  and  most  peremptory  directions  should 
be  given  to  the  parents  by  the  medical  attendant  that  nothing  whatever 
should  be  taken  except  at  regular  meals.  If  the  child  refuses  or  only  half 
gets  through  its  breakfast,  this  should  by  no  means  be  supplemented  by  a 
second  edition  at  the  parents'  table,  or  a  tasty  lunch  to  make  up  for  the 
morning's  deficiencies.  It  is  wiser  by  far,  if  the  breakfast  is  but  half  taken, 
to  let  the  child  wait  till  the  next  meal  ;  a  little  starvation  can  do  no  harm,  at 
any  rate  much  less  than  over-indulgence  and  the  formation  of  bad  habits. 
The  importance  of  fresh  air  and  change  of  scene  in  cases  of  habitual  indi- 
gestion can  hardly  be  over-estimated.  The  worst  kind  of  exercise  is  a  '  con- 
stitutional '  taken  with  the  nurse  or  governess  ;  outdoor  games  of  various 
kinds,  gymnastics,  riding,  or  driving,  or  some  form  of  recreation  which  will 
occupy  the  mind  and  give  an  interest  to  the  exercise,  are  far  preferable  to 
any  dull  routine.  A  change  to  the  seaside,  or  some  bracing  elevated  inland 
site  where  there  is  a  keen  cool  air,  will  often  work  wonders  in  these  cases. 
It  must,  however,  be  remembered  that  such  cases  are  often  worse,  or  there 
is  no  improvement,  at  first ;  children  when  first  removed  to  the  seaside  are 
apt  to  do  too  much  and  eat  too  much  ;  they  are  over-tired  and  fretful  at 
night,  and  attacks  of  dyspepsia  or  perhaps  eczematous  or  other  eruptions 
occur.     A  caution  is  often  necessary  to  prevent  this. 

It  is  wiser  in  most  cases  to  lay  down  a  complete  diet  chart  for  the  gui- 
dance of  the  parents,  though  a  certain  latitude  must  necessarily  be  permitted 
on  account  of  varying  tastes.  The  following  diet  tables  may  be  taken  as 
samples,  which  can  be  modified  according  to  circumstances: 


CJironic  Intestinal  Catarrh  1 1 1 

Diet  for  a  child  of  5  to  7  years,  indlgrestlon  not  severe  : 

Breakfast,  8  a.m. — A  breakfast  cupful  (8  oz.)  of  bread  and  milk,  made 
from  whole  meal  bread  ;  a  teaspoonful  of  malt  extract  may  be  added  ; 
this  may  be  followed  two  or  three  times  a  week  by  the  yolk  of  a  Hghtly  boiled 
^g%  on  strips  of  toast,  or  a  piece  of  toast  and  dripping  or  bacon  fat. 

Dintier,  X2  to  i  P.M. — A  broiled  mutton  cSxo^,  finely  mi  treed,  or  fresh  white 
fish,  with  mashed  potato,  spinach,  or  French  beans  ;  to  be  followed  by 
ground  rice  pudding  or  a  baked  apple,     Milk  to  drink. 

Tea,  4  to  5  p.m. — A  cup  of  cocoa  and  milk,  with  toast  or  stale  bread. 

S upper,  7  P.M. — A  cup  of  beef  tea  or  mutton  broth. 

In  the  more  severe  and  protracted  cases  it  is  well  to  avoid  farinaceous 
food  as  much  as  possible,  as  recommended  by  Dr.  Eustace  Smith. 

Breakfast,  8  A.M. —  Half  to  three-ciuarters  of  a  pint  of  fresh  milk,  alkah- 
nised  by  twenty  drops  of  the  saccharated  solution  of  lime  ;  a  slice  of  toast 
with  yolk  of  Qgg,  or  fresh  fish. 

Dinner,  12-1  P.M. — A  small  mutton  chop  or  boiled  sole,  a  thin  slice 
of  stale  bread,  with  half  to  a  wineglassful  of  sherry  or  bitter  beer,  well 
diluted. 

Tea,  4-5  P.M. — Same  as  breakfast. 

Supper,  7  P.M. — A  cup  of  beef  tea. 

In  some  of  these  cases  of  chronic  dyspepsia,  especially  where  the  stools 
are  pale,  the  amount  of  milk  which  the  child  takes  must  be  lessened  in 
quantity — the  milk  given  being  much  diluted  with  cocoa  made  with  water, 
or  peptonised  milk  may  be  given. 

In  all  cases  of  habitual  indigestion  it  is  of  much  importance  to  sponge 
every  morning  with  cold  or  tepid  water  (6o°-7o°),  keeping  the  child's  feet  in 
warm  water  during  the  process,  if  it  is  subject  to  cold  feet  or  has  a  sluggish 
circulation.  A  shower  bath  is  often  of  much  service.  After  the  morning's 
bath  friction  with  as  rough  a  towel  as  the  child's  skin  can  stand  should  be 
used.  The  child's  dress  should  consist  of  woollen  garments  next  to  the  skin. 
and  every  chance  of  getting  cold  should  be  avoided. 

The  medicines  which  are  of  the  greatest  value  in  these  cases  are  nitric 
acid  in  corribination  with  helaline  and  pepsine  (iT^xv  to  ll^xxx  of  the  liq.), 
or  euonymin  and  pepsine  may  be  given.  Arsenic  is  often  of  much  value, 
but  requires  to  be  given  in  increasing  doses  to  bring  out  its  full  value.  For 
a  child  of  seven  years,  three-drop  doses  may  be  given,  and  gradually 
increased  to  six  drops,  or  it  may  be  given  in  small  granules,  which  are 
readily  taken  by  children,  preferably  an  hour  after  food.  At  the  same  time 
it  is  well  to  order  a  saline  purgative,  which  shall  keep  the  bowels  relaxed 
rather  than  loose.  Alkalies  with  senna  or  rhubarb  are  often  prescribed 
with  much  advantage.  (F.  38,  39.)  Later,  when  convalescence  is  established, 
acids  and  bitters  should  be  given.     (F.  36,  2)7 1  40-) 

If  the  bowels  keep  confined,  a  small  granule  containing  half  a  grain  of 
aqueous  extract  of  aloes  may  be  taken  at  dinner  time  daily  ;  in  many  cases 
a  grain  will  be  required  to  keep  the  bowels  well  open.  This  may  be  sup- 
plemented, especially  if  the  stools  are  pale,  by  an  ounce  or  two  of  Hun- 
yadi  water,  to  which  an  equal  quantity  of  warm  water  has  been  added,  to  be 
taken  two  or  three  times  a  week  before  breakfast,  or  Rubinat  or  Friedrichs- 
hall  water,  half  a  wineglass  to  a  wineglassful  in  warm  water,  or  a  teaspoonful 


112  Diseases  of  the  Digestive  System 

of  effervescing  Carlsbad  salts,  may  be  taken  before  breakfast  two  or  three 
times  a  week,  and  decreased  or  increased   according  to  the  state  of  the 

bowels. 

Dilatation  of  Stomach.— Dilatation  of  the  stomach  during  infancy  is 
commonly  the  result  of  a  long-continued  gastric  catarrh  ;  in  rare  cases  it  is 
secondary  to  a  congenital  stenosis  of  the  pylorus  or  duodenum,  or  upper 
part  of  the  small  intestine.  In  the  minority  of  cases  the  dilatation  takes 
place  rapidly,  as  in  acute  gastric  or  gastro-intestinal  catarrh,  or  in  '  cholera 
infantum,'  but  it  is  far  more  frequently  found  in  weakly  infants  or  children 
who  have  suffered  for  months  from  chronic  dyspepsia  and  who  are  probably 
ancemic  and  rickety.  It  is  easy  to  understand  that,  if  the  digestive  fluids 
are  weak  and  insufficient  to  properly  digest  the  food,  the  curd  of  milk  and 
starches  decompose  in  the  stomach,  and  gases  are  given  off  in  large  quanti- 
ties. The  constant  distension  of  the  stomach  keeps  the  muscular  walls  on 
the  stretch,  the  muscular  fibres  become  thin  and  atrophic,  and  the  distended 
condition   tends  to  become  permanent.     The  muscular  mucous  membrane, 

including     the     glandular 

j^       elements,  is  wasted.      The 

^      ^^      effect  of  a  dilated  stomach 

is  to  add  to  the  dyspeptic 

troubles  ;     like    a    dilated 

'       and  powerless  bladder,  its 

contents  become  stagnant 

^       and  decompose  ;   it  never 

■-^  ,  thoroughly   empties    itself, 

---__  but  always  contains  much 

-     -  -*^^^^_^._^,^       mucus    and    decomposing 

Fig.     ,5.— Stenosis    of   Pylorus,   showing    narrow    channel,         ^Urd       of      milk.  These 

hypertrophy   of    muscular   fibres,    and    hyperplasia   of  the         dilated       StOmachs       SOme- 
mucous  coat  ;  death  at  six  weeks.     (Life  size.)    (From  a        ^;  re^^r\^     an    pnnrmnnc; 

drawing  by  w.  E.  Fothergiii.)  timcs   reacn  an  enormous 

size.  Henschel  records  a 
stomach  of  an  infant  two  weeks  old  with  a  capacity  of  190  cc.  (normal 
70  cc.)  ;  an  infant  of  three  months  with  a  stomach  of  a  capacity  of  485  cc. 
(normal  150  cc.)  ;  another  of  four  months,  of  500  cc.  (normal,  180  cc.)  ; 
and  another  of  ten  months  of  650  cc.  (normal,  300  cc).  The  symptoms 
are  not  very  definite,  and  we  have  on  several  occasions  discovered  post 
niortem  a  considerably  dilated  stomach,  which  we  had  not  detected  during 
life.  There  is  chronic  dyspepsia,  discomfort  after  food,  distension  of  the 
stomach  with  gases,  coated  tongue,  and  in  some  cases  chronic  vomiting. 
The  diagnosis  may  be  difficult  ;  in  some  cases  the  limits  of  the  dilated 
stomach  may  be  mapped  out  by  percussion,  but  this  can  only  be  done 
if  the  colon  and  small  intestines  are  not  distended.  If  the  colon  is 
much  distended,  it  will  probably  be  impossible  to  distinguish  between  the 
tympanitic  note  produced  by  percussing  the  stomach  and  that  produced  by 
percussing  the  colon.  A  splashing  sound  may  sometimes  be  produced  by 
shaking  the  child,  in  cases  of  dilated  stomach,  il  there  is  much  fluid  in  the 
stomach.  The  prognosis  is  not  necessarily  bad,  as  there  can  be  little  doubt 
that  under  favourable  conditions  the  stomach  may  recover  itself  The 
treatment  is  that  of  chronic  dyspepsia  :  washing  out  is  especially  useful. 


Dilatatioti  of  the  StouiacJi  i  j  3 

Dilatation  of  the  stoniacli,  sometimes  extreme  in  degree,  is  present  in 
congenital  obstruction  of  the  duodenum  and  ileum.     (See  p.  149.) 

Cong-enital  Stenosis  of  the  Pylorus. — In  rare  cases  there  is  a  congeni- 
tal stenosis  of  the  pylorus  with  a  secondary  dilatation  and  hypertrophy  of  the 
walls  of  the  stomach.  We  have  seen  several  such  cases.  The  infant,  which 
is  born  healthy,  begins  to  vomit  at  about  the  end  of  the  first  week  ;  the  vomit- 
ing continues,  large  quantities  are  '  pumped  up '  till  the  stomach  is  empty. 
The  vomiting  then  ceases  for  perhaps  12  or  24  hours,  and  the  vomiting 
comes  on  again.  No  bile  is  vomited,  the  stools  are  small  and  constipated. 
Wasting  quickly  takes  place,  and  death  from  exhaustion  occurs  in  6  or  8 
weeks.  Incases  where  the  stenosis  is  slight,  the  symptoms  are  less  marked, 
and  life  may  be  prolonged  for  6  months  or  more.  But  little  can  be  done  in 
the  way  of  treatment ;  at  the  post-?noriem  the  pylorus  is  found  thickened, 
forming  a  tumour,  which  has  in  some  cases  been  felt  during  life,  the  thick- 
ening being  due  to  hypertrophy  of  the  muscular  layer,  the  mucous  coat  is 
also  thickened.  The  pyloric  channel  is  narrow,  and  the  walls  of  the  stomach 
hypertrophied.     (See  fig.  15.) 


Fig.  16.— Hour-glass  constriction  of  ston:iach,  from  an  infant  of  five  months.  The 
muscular  walls  of  the  narrowed  part  were  much  thicker  than  the  walls  of  the  rest  of 
the  stomach.     (Natural  size.) 

Malformations  of  the  Stomach. — These  are  certainly  uncommon,  but 
a  slight  degeee  of  hour-glass  constriction  which  had  been  unsuspected  during 
life  may  at  times  be  found  at  post-mortems.  In  a  case  of  our  own  in  which 
we  made  the  section,  but  did  not  see  the  infant  during  life,  there  was  a  well- 
marked  contraction  in  the  central  portion  of  the  stomach.  (See  fig.  16.) 
There  was  a  history  of  constant  vomiting  during  life.  In  such  a  case  it  is 
very  possible  that  there  is  no  real  malformation  ;  but  it  is  difhcult  to  say 
whether  the  narrowing  is  due  simply  to  a  spasmodic  contraction  of  the  normal 
muscular  coat  at  this  spot,  or  whether  there  was  a  true  hypertrophy. 

Carcinoma  of  the  Stomach.— New  growths  in  the  alimentary  canal  are 
exceedingly  rare  in  early  life.  We  have  met  with  one  case,  but  the  new 
growth  was  more  duodenal  than  gastric.     The  case  was  shortly  as  follows  : 

Oliver  G. ,  aged  8  years,  was  admitted  to  hospital  Sept.  i,  1890.  He  was  a  thin  boy, 
with  distended  abdomen  and  symptoms  of  cystitis.  There  had  been  no  vomiting,  pain, 
or  diarrhoea.  The  abdominal  distension  was  considerable  :  the  coils  of  intestines  could 
be  distinctly  seen  through  the  abdominal  walls.     There  was  no  tenderness,  and  no  tumour 

I 


114  Diseases  of  the  Digestive  System 

could  be  felt.  He  was  discharged  February  21,  1891,  somewhat  improved,  having  made 
flesh  during  his  stay.  He  was  re-admitted  April  23,  1891.  The  abdomen  was  distended 
and  tender,  and  a  tumour  could  be  felt  below  the  edge  of  the  liver,  to  the  right  of,  and 
about  the  same  level  as,  the  umbilicus.  There  were  frequent  attacks  of  severe  colicky 
pains.  He  gradually  emaciated,  and  died  May  15.  The  post-mortem  showed  that  the 
transverse  colon  near  the  hepatic  flexure,  the  duodenum  and  omentum,  were  matted 
together ;  the  stomach  was  dilated,  and  its  walls  thickened.  The  pyloric  opening  just 
admitted  the  forefinger  ;  on  the  cardiac  side  of  the  pylorus  were  two  small  growths,  the 
size  of  peas  ;  on  the  duodenal  side  there  was  an  irregular  cavity,  the  walls  of  the  first  part 
of  the  duodenum  ha\'ing  been  destroyed  by  a  new  growth  ;  lower  down  were  some  pol3q3oid- 
looking  growths  ;  below  these  the  mucous  membrane  was  normal.  Microscopical  exami- 
nation showed  the  growth  to  be  a  columnar  epithelioma. 

ITlcer  of  Stomach. — Tubercular  ulcers  of  the  stomach  are  rare  in 
children  ;  we  have  seen  only  one  example.  When  puberty  is  passed  simple 
ulcers  may  occur.  We  have  known  severe  h^ematemesis  occur  from  tuber- 
cular ulcers  in  the  jejunum. 

Intestinal  "Worms 

The  worms  which  most  commonly  infest  children  are  the  thread  worms, 
round  worms,  and  tape  worms,  of  which  the  former  are  the  most  common. 

Tbread  "Worms  (Oxyuris), — These  troublesome  pests  inhabit  the  lower 
bowel,  i.e.  caecum  and  appendix,  colon,  sigmoid  flexure,  rectum,  and  the 
vagina;  an  unhealthy  state  of  the  mucous  membrane  with  sluggish  bowels  ap- 


Fig.  17. — Oxyuris  vennicularis^  female.     Highly  magnified. 
(Quain's  '  Dictionary  of  Medicine.') 

pearing  to  favour  their  development.  To  the  naked  eye  they  appear  like  short 
pieces  of  white  thread  :  under  a  low  power  the  females,  which  are  the  more 
numerous,  are  seen  to  taper  at  each  end,  and  their  uterine  ducts  will  be  seen 
to  contain  numerous  oval-shaped  ova,  some  of  the  latter  containing  embryos. 
These  parasites  gain  entrance  into  the  system  by  the  ova  being  taken  in  the 
fsod,  or  perhaps  more  frequently  by  means  of  the  ova  adhering  to  the  fingers 
of  those  already  affected;  they  are  thus  conveyed  directly  or  indirectly  to 
others.  The  extreme  fertility  of  these  worms  makes  it  certain  that  any  one 
who  is  affected  with  thread  worms  and  is  not  of  scrupulously  cleanly  habits 
will  have  ova  adhering  to  the  neighbourhood  of  the  anus  which  may  be 
transferred  by  the  fingers  to  the  individual's  own  mouth  or  to  others.  The 
symptoms  are  very  uncertain,  the  diagnosis  being  usually  made  by  the 
patient's  friends  detecting  the  parasites  in  the  chamber  vessel  used  by  the 
child.  The  most  common  symptom  to  call  attention  to  the  presence  of  thread 
worms  is  the  irritation  and  itching  which  they  are  apt  to  give  rise  to  at  the 
anus  or  entrance  to  the  vagina.  Girls  will  suffer  from  excessive  discharge 
of  mucus  from  the  vagina,  sometimes  containing  blood,  from  the  presence  of 
oxyurides  in  the  vagina  or  the  result  of  scratching.  In  many  cases  the 
presence  of  thread  worms  seems  to  give  rise  to  no  symptoms  M'hatever. 
Weakly  anaemic  children  with  sluggish  bowels  are  most  often  affected.     The 


Intestinal   Worms —  Thread   Worms 


115 


treatment  consists  in  expelling  the  worms,  preventing  their  rc-entrance,  and 
in  improving  the  health  of  the  child  so  that  it  is  less  likely  to  provide  a  favour- 
able cultivation  ground  for  these  unwelcome  guests.  The  first  indication  is 
best  fulfilled  by  a  sharp  purge  to  expel  or  else  to  drive  them  into  the  lower 
bowel,  to  be  followed  by  enemata  to  destroy  those  present  in  the  colon  and 
rectum,  and  wash  away  any  excess  of  mucus  present  ;  a  grain  to  two  grains  of 
calomel,  in  combination  with  two  or  three  grains  of  resin  of  scammony,  may 
be  given  to  children  of  three  to  eight  years  of  age  overnight  ;  and  the  following 
evening,  if  the  bowels  have  been  well  acted  upon,  an  enema  of  infusion  of 
quassia  as  large  as  can  be  given  should  be  used.  It  will  be  well  to  repeat  the 
enemata  every  other  evening  for  a  week  or  two.  Great  care  should  be  exercised 
to  see  that  the  child  is  washed  about  the  genitals  with  soap  and  water  after 
each  stool  to  prevent  re-infection.  Injections  should  be  used  repeatedly  to 
free  the  vagina  from  any  of  these  worms,  if  there  is  any 
vaginitis  or  irritation.  Weak  carbolic  acid  lotions  will 
answer  very  well,  and  some  dilute  red  oxide  of  mercury 
ointment  (1-3)  may  be  smeared  at  the  entrance  to  the 
vagina.  The  general  health  of  the  child  must  also  be 
thought  of  and  a  careful  diet  prescribed,  excess  of 
sweets  and  starches  being  avoided.  If  constipation 
exist,  Rubinat  or  Hunyadi  water  should  be  given  every 
other  morning  before  breakfast,  in  sufficient  quantity 
to  produce  a  soft  stool  without  purging  :  sulphate  of 
iron,  gr.  h-]-,  with  spirits  of  chloroform  and  orange 
flower  water,  twice  a  day,  is  often  very  useful.  Cod- 
liver  oil  in  selected  cases  is  of  great  service. 

Naphthalin  is  an  effective  anthelmintic  for  thread  worms,  but  it  is  dis- 
agreeable to  take.  It  may  be  given  as  suggested  by  Schmitz  in  doses  of  two 
to  five  grains  four  times  a  day  till  eight  doses  have  been  taken  ;  repeat  in 
a  week's  time.  If  necessary  the  dosing  must  be  repeated  after  a  week's 
interval.  Enemata  of  corrosive  sublimate  (1-1,000)  after  the  bowels  have 
been  freely  xnoved  is  an  effectual  local  application. 

Round  ■Worms  (Ascaris  lumbricoides). — The  common  round  worm 
measures  from  four  to  twelve  inches  in  length,  the  females  being  somewhat 
longer  than  the  males  ;  they  are  reddish  white  and  have  more  or  less  resem- 
blance to  common  earth  worms.  They  mostly  inhabit  the  small  intestines, 
but  are  apt  to  wander  into  the  stomach,  large  intestines,  or  even  into  the 
gall  bladder.  Several  may  exist  in  the  intestine  at  the  same  time,  in  ex- 
ceptional instances  many  hundreds  may  be  present.  They  gain  entrance 
into  the  system  by  means  of  their  ova,  which  are  swallowed  with  the  food  ; 
the  shells  surrounding  the  ova  are  dissolved  by  the  gastric  juice,  setting  free 
the  embryos.  The  symptoms  produced  by  the  presence  of  round  worms 
cannot  be  certainly  distinguished  from  those  of  dyspepsia  or  intestinal  catarrh, 
with  which  the  ascarides  are  so  commonly  associated.  The  passage  of  a 
round  worm  per  rectum  is  often  the  first  thing  to  call  attention  to  the  subject ; 
on  the  other  hand,  mothers  often  dogmatically  assert  that  their  child  has 
worms  because  he  '  picks  his  nose  '  and  his  '  food  appears  to  do  him  no  good.' 
The  latter  symptoms,  it  is  needless  to  say,  are  not  diagnostic  of  the  presence 
of  worms,  but  of  an  unhealthy  state  of  the  alimentary  canal.     The  presence 


Fig.  18.— Eggsof  O-fj/- 
ttrls  verinicula7'is  en- 
closing embryos  X450 
diam.  (Quain's  '  Dic- 
tionary of  Medicine.') 


1 1 6  Diseases  of  the  Digestive  System 

of  one  or  two  round  worms  rarely  produces  any  symptom  jz^(?r  se,  unless  they 
pass  into  the  stomach  or  bile  duct.  In  larger  numbers  they  may  give  rise  to 
colicky  pains,  especially  at  night;  diarrhoea,  vomiting,  and  symptoms  of  ob- 
struction of  the  bowels  have  occasionally  resulted.  In  rare  instances  worms 
have  found  their  way  into  the  peritoneal  cavity  and  been  discharged  with 
the  contents  of  an  abscess  through  the  abdominal  wall.  The  treatment  is  not 
as  difficult  as  the  diagnosis.  Santonin  combined  with  calomel  or  castor  oil 
should  be  given,  and  is  almost  certainly  successful  after  a  dose  or  two  has 
been  given.  Santonin,  gr.  j-iij,  calomel,  gr.  |-j,  may  be  given  overnight,  and 
some  fluid  magnesia  or  other  saline  next  morning  before  breakfast.  Or  the 
santonin  dissolved  in  two  or  three  teaspoonfuls  of  castor  oil  may  be  given 
laefore  breakfast.  The  santonin  may  be  repeated  once  or  twice,  but  not 
oftener,  until  the  physiological  effects  (if  any  have  been  produced)  have 
passed  off.  If  the  santonin  cause  vomiting,  smaller  doses  should  be  tried  or 
■compound  scammony  powder  substituted. 

Tape  'Worms  are  as  common  in  children  as  in  adults,  both  the  Tcenia 
soliicin  and  T.  niediocanellata  being  found.  Infants  and  young  children  less 
■often  act  as  hosts  for  tapeworms,  but  they  have  been  found  in  infants  under 
a  year  old.  Attention  is  first  called  to  the  fact  by  the  passage  of  the  joints 
or  proglottides  in  the  stools.  Older  children  will  often  complain  of  pain  in 
ihe  epigastrium,  and  peculiar  movements  are  felt  inside  ;  they  are  apt  also 
to  lose  flesh  and  suffer  from  various  dyspeptic  symptoms.  The  difficulty 
of  dislodging  the  greater  part  of  the  creature  is  not  great,  but  the  head  is  not 
:so  easily  expelled,  especially  that  of  the  TcBnia  solium.  The  success  of  the 
treatment  by  means  of  the  administration  of  male  fern  depends  upon  the  in- 
testine containing  as  little  food  as  possible.  A  dose  of  castor  oil  should  be 
given  overnight  sufficiently  large  to  act  freely  before  morning ;  twenty  to 
thirty  drops  of  etherial  extract  of  male  fern  (freshly  prepared)  should  be  given 
in  half  an  ounce  of  mucilage  and  water  before  breakfast ;  breakfast  should 
consist  of  some  light  refreshment  such  as  beef  tea  :  at  noon  another  dose  of 
■castor  oil  should  be  given,  which  will  act  in  the  course  of  the  day,  bringing 
away  the  intruder.  Careful  search  should  be  made  for  the  head,  bearing  in 
mind  that  the  joints  are  likely  to  break  about  an  inch  from  the  head,  that  the 
latter  is  about  the  size  of  a  large  pin's  head,  and  the  thickness  of  the  worm 
itself  near  the  head  is  only  that  of  a  stout  thread. 

If,  after  careful  search  by  a  competent  observer,  the  head  is  not  discovered 
in  the  stools,  after  a  few  days  the  treatment  may  be  repeated,  but  it  is  not 
wise  to  continue  to  repeat  the  male  fern,  as  toxic  symptoms  are  apt  to  arise. 
Decoction  of  pomegranate  root  may  be  substituted  if  it  is  necessary  to  con- 
tinue the  treatment. 

Ascites 

Fluid  is  sometimes  present  in  the  peritoneal  cavity  of  the  child  without 
dropsy  elsewhere,  and  it  may  be  difficult  to  decide  as  to  its  cause.  The 
diagnosis  of  ascites  when  it  forms  part  of  a  general  dropsy,  as  in  cardiac 
disease  or  renal  disease,  is  easy  and  does  not  call  for  special  comment. 

An  ascites  which  is  primary  in  a  child  is  usually  the  result  of  some  lesion  of 
the  peritoneum,  as  chronic  peritonitis,  or  the  result  of  portal  obstruction  such 
.as   mediastinitis,  cirrhosis,  or  perihepatitis.     The  detection  of  a   large   or 


Ascites  117 

moderate  quantity  of  fluid  in  the  peritoneal  cavity  is  not  difficult,  the  per- 
cussion note  being  dull  in  the  flanks,  while  the  region  round  the  umbilicus  is 
tympanitic  m  consequence  of  the  distended  intestines  floating  upwards  when 
the  patient  is  lying  on  his  back  ;  change  of  position  on  to  the  side  will  float 
the  intestines  to  the  highest  point,  and  the  flank  which  is  uppermost  will  now 
be  resonant.  While  change  of  the  patient's  position  will  thus  cause  the  fluid 
to  gravitate  to  the  lowest  point  if  it  is  free  in  the  peritoneal  cavity,  it 
must  be  borne  in  mind  that  in  chronic  peritonitis  there  may  be  a  mattmg 
together  of  the  intestines  which  prevents  them  from  floating  upwards,  and 
consecjuently  there  may  be  no  alteration  in  the  percussion  note  after  change 
of  position.  The  amount  of  dulness  to  percussion  may  vary  from  day  to  day 
according  to  the  varying  distension  of  the  intestines.  In  ascites  the  super- 
ficial veins  of  the  abdomen  are  usually  enlarged,  the  skin  becomes  shiny 
and  stretched  if  the  fluid  is  excessive,  and  often  the  umbilicus  is  protruded 
and  pouched  out,  containing  fluid  which  can  be  pressed  back  into  the 
abdominal  cavity.  The  detection  of  a  small  cjuantity  of  fluid  in  the  abdo- 
men is  difficult,  especially  when  the  intestines  are  much  distended  with 
gas  and  the  large  bowel  is  loaded  with  faeces,  the  latter  giving  a  more 
or  less  dull  percussion  note  in  the  flanks.  Fluctuation  may  be  felt 
by  passing  the  finger  into  the  rectum  ;  fluid  may  thus  be  detected  in 
the  pelvis.  A  careful  observer  is  hardly  likely  to  mistake  simple  dis- 
tension of  the  intestines  with  gas  for  ascites  ;  the  thrill  imparted  to  the 
contained  fluid  by  gently  tapping  the  flank  is  absent  in  the  flatulent  dis- 
tension, and  on  percussion  the  abdomen  is  universally  tympanitic.  The 
diagnosis  of  the  cause  of  the  ascites  is  often  difficult,  as  a  large  accumulation 
of  fluid  may  be  due  to  chronic  peritonitis  and  closely  resembles  an  ascites  due 
to  portal  obstruction.  Chronic  peritonitis  may  be  quite  unaccompanied  by 
pain  or  tenderness  from  first  to  last,  and  the  fluid  may  be  excessive.  Any 
matting  or  induration  of  the  omentum  or  intestines  to  be  felt  through  the 
abdominal  walls,  or  a  slight  evening  rise  in  the  temperature  or  signs  of  tuber- 
culosis elsewhere  (as  in  the  testis),  or  chronic  diarrhoea,  would  be  in  favour 
of  chronic  peritoneal  tuberculosis.  A  normal  temperature,  the  ascitic  fluid 
freely  movable,  the  general  health  good,  slight  jaundice  or  bile  pigment  in 
the  urine,  would  be  in  favour  of  portal  obstruction,  as  cirrhosis  or  medias- 
tinitis.  If  the  fluid  .is  localised  by  the  presence  of  adhesions,  and  does 
not  occupy  the  whole  peritoneal  cavity,  it  is  probably  due  to  tuberculosis. 
The  possibility  of  hydatids  of  the  peritoneum  must  be  borne  in  mind.  An 
enlargement  of  the  spleen  with  ascites  suggests  cirrhosis  of  the  liver. 


1 1 8  Diseases  of  the  Digestive  System 


CHAPTER  VII 

DISEASES   OF   THE   DIGESTIVE   SYSTEM — {continued) 

Acute  Peritonitis 

Acute  general  peritonitis  is  not  an  uncommon  disease  during  infancy  and 
childhood.  It  occurs  as  a  primary  disease,  but  more  often  the  inflammation 
spreads  from  some  organ  or  structure  with  which  the  peritoneum  comes  into 
relation.  It  sometimes  follows  a  blow  or  some  injury  to  the  peritoneum. 
The  foetus  also  suffers  from  peritonitis  perhaps  more  subacute  than  acute, 
and  the  adhesions  which  are  left  surrounding  and  matting  the  intestines  are 
apt  to  interfere  with  the  growth  and  development  of  the  gut,  and  lead  to 
stenosis  or  obstruction  by  narrowing  the  bowel  or  tying  it  up  in  coils. 
Acute  peritonitis  occurs  in  the  newly  born,  secondary  to  ;  arteritis  or 
septicaemia  ;  but  such  cases  are  rare  in  private  practice.  Apart  from  these 
cases,  peritonitis  is  not  common  in  infants  and  young  children.  Dr.  West 
mentions  a  case  of  idiopathic  peritonitis  occurring  in  an  infant  of  seven 
months,  which  proved  fatal  in  six  days  ;  the  attack  was  sudden,  accom- 
panied by  vomiting  and  abdominal  distension  ;  after  death,  lymph  and 
serous  fluid  were  found  in  the  abdominal  cavity.  We  have  known  it  in 
infants  and  young  children  to  spread  from  a  suppurating  mesenteric  gland. 
Acute  peritonitis  occurs  in  older  children  by  no  means  infrequently,  super- 
vening, without  known  cause,  in  the  midst  of  apparent  health  ;  in  other 
cases  there  is  a  history  of  a  chill,  or  a  blow  upon  the  abdomen,  and  at  the 
post-mortem  there  is  nothing  to  indicate  where  the  inflammation  commenced. 
Not  infrequently  the  peritonitis  is  the  result  of  some  lesion  in  the  caecum, 
vermiform  appendix,  or  mesenteric  glands.  It  sometimes  occurs  in  tuber- 
cular subjects  :  thus  a  phthisical  boy  of  nine  years  old  was  suddenly  seized 
w^ith  pain  in  the  abdomen  and  vomiting,  and  died  in  ten  days  :  at  the 
post-mortem  an  acute  general  peritonitis  was  present,  and  also  adhesions 
from  old  peritonitis  and  some  calcified  mesenteric  glands.  Acute  pei-itonitis 
may  be  caused  by  the  spread  of  inflammation  from  other  parts,  as  from  the 
pleura,  an  empyema  bursting  through  the  diaphragm,  from  the  pericardmm, 
ulcers  in  the  stomach,  duodenum,  ileum,  or  ceecum,  or  from  intussusception. 
It  may  occur  in  the  course  of  typhoid  fever  from  perforation  of  the 
intestine  and  extravasation  of  faeces.  It  is  rare  in  the  course  of  scarlet 
fever,  but  it  is  not  uncommon  in  the  last  stages  of  the  succeeding  nephritis, 
when  urjemic  phenomena  have  set  in  ;  it  is  then  mostly  of  a  purulent 
character.     We  have  seen  peritonitis  post  mortem,  which  was   associated 


Acute  Peritonitis  119 

with  an  acute  enteritis,  and  it  seems  probable  tliat,  in  some  cases,  an 
apparently  idiopathic  |)eritonitis  is  set  up  by  a  bacterial  infection  from  the 
intestines. 

Syiitptoiiis  and  Course. — The  symptoms  of  acute  peritonitis  in  the  infant 
and  child  are  by  no  means  always  as  characteristic  as  they  are  in  the  adult, 
and  cases  will  sometimes  occur  where  extensive  peritonitis  is  found  at  the 
post-mortem  which  was  not  suspected  during  life,  especially  when  it  super- 
\enes  in  the  course  of  some  other  disease. 

The  attack  usually  begins  with  vomiting,  sometimes  diarrhoea,  and  great 
pain  and  tenderness  in  the  abdomen  referred  to  the  region  of  the  umbilicus  : 
the  amount  of  tenderness  on  pressure  varies  even  in  cases  where  no  opium 
has  been  given,  and  where  the  patient  is  under  the  influence  of  this  drug  pain 
may  be  entirely  absent.  Constipation  after  the  onset  is  a  marked  feature 
when  the  attack  is  established,  no  fasces  and  often  no  wind  passing  by  the 
bowel  ;  the  vomiting"  is  constant,  the  distension  of  the  bowels  very  great,  so 
that  the  coils  of  distended  'small  intestines  may  be  seen  through  the  abdo- 
minal walls,  and  the  case  may  readily  be  assumed  to  be  obstruction  of  the 
bowels  from  some  mechanical  cause.  Though  no  complete  obstruction 
exists,  yet  the  coils  of  intestine  are  seen  post  mortem  to  make  sharp  turns 
on  one  another,  '  kinks '  being  formed,  which,  with  the  layers  of  lymph  on 
their  surface,  must  seriously  impede  the  passage  of  their  contents.  The 
paralysis  of  the  muscular  coat  of  the  bowel,  by  diminishing  or  arresting  the 
normal  peristaltic  movements,  further  prevents  the  onward  movement  of  the 
intestinal  contents.  The  vomiting  is  mostly  constant  as  long  as  food  is 
given  ;  undigested  food,  bile,  and  sour-smelling  intestinal  contents  may  be 
brought  up,  but  the  vomited  matters  are  seldom  faecal  as  they  are  in  hernia 
or  intussusception.  There  is  usually  moderate  fever,  the  temperature  being 
101°  to  102°  F.,  but  a  normal  or  subnormal  temperature  may  persist  through- 
out the  case,  and  distension  is  not  always  present.  The  pulse  is  nearly 
always  considerably  C|uickened. 

In  the  later  stages  the  abdominal  distension  is  often  extreme,  the  coils  of 
distended  intestine  may  be  readily  discernible  through  the  walls  of  the  abdo- 
men, the  face  becomes  pinched  and  blue,  the  pulse  c^uick  and  thready,  and 
the  patient  dies  collapsed,  often  suddenly  at  the  last.  While  this  is  the  all 
but  universal  ending  of  a  case  of  general  peritonitis,  when  the  symptoms  have 
fully  declared  themselves,  cases  undoubtedly  occur  in  which  the  diagnosis  of 
peritonitis  is  made,  on  account  of  the  distension  and  pain  in  the  abdomen, 
^\•hich  gradually  improxe  under  treatment,  and  finally  recover.  There  is 
reason  to  suppose  that  cases  of  acute  peritonitis  will  occasionally  get  well, 
even  when  the  attack  has  been  a  general  one.  In  other  cases  the  symptoms 
of  a  local  suppuration,  hectic,  local  tenderness,  and  swelling,  succeed  to  those 
of  a  general  peritonitis.  In  such  cases,  presumably,  there  may  have  been 
a  local  peritonitis  from  the  first. 

The  following  cases  will  illustrate  some  of  the  above  remarks  : 

Acute  Suppurative  Peri/o/zitis. — John  C. ,  aged  7  years.  The  family  history  was  good. 
He  had  been  a  strong  boy  up  to  the  time  of  his  fatal  illness.  No  cause  could  be  assigned 
for  his  sickness.  Four  days  before  admission  to  hospital  he  complained  of  pain  in  the 
'  stomach  ;  '  there  was  vomiting  and  constipation.  On  admission  to  hospital  on  the  fifth 
day  of  his  illness,  the  face  wore  an  anxious  expression,  as  if  he  was  in  pain  ;  the  abdomen 


I20  Diseases  of  the  Digestive  System 

was  distended  and  tense,  and  tympanitic  and  tender  to  the  least  touch  ;  his  legs  were 
drawn  up  ;  he  constantly  vomited  dark,  sour-smelling,  almost  fascal  stuff.  The  urine, 
drawn  off  by  a  catheter,  contained  albumen.  All  food  and  drink  by  the  mouth  were 
stopped,  and  he  was  given  ten-minim  doses  of  tinct.  opii  every  second  hour  till  three  doses 
had  been  given.  He  passed  a  restless  night,  yet  was  drowsy  from  the  effects  of  the 
opium.  He  gradually  sank,  dying  on  the  evening  of  the  sixth  day  of  his  illness.  At  the 
post-mortem,  on  opening  the  abdomen,  a  few  ounces  of  offensive  pus  escaped  ;  the  surface 
of  the  intestines  was  injected  ;  the  bowels  were  matted  together  with  lymph  ;  there  was  no 
strangulation.  The  caecum  and  vermiform  appendix  were  normal  ;  there  were  patches 
of  intense  congestion  on  the  mucous  surface  of  the  ileum,  and  a  sharply  cut  ulcer  (not  per- 
forating), half  an  inch  in  diameter,  some  two  feet  above  the  caecum.  No  certain  cause 
for  the  acute  peritonitis  was  found,  unless  it  be  assumed — which  is  indeed  not  improbable 
— that  an  enteritis  existed  in  the  first  instance,  and  that  the  peritonitis  was  secondary. 

Acute  Peritonitis. — Boy,  13  years,  said  to  be  delicate,  but  never  ailed  anything.  He 
played  with  his  brothers  on  Wednesday  afternoon,  tumbling  about  on  the  floor — no  definite 
history  of  a  blow.  Thursday  he  did  not  eat  his  breakfast,  and  said  he  felt  sick  ;  vomited 
several  times  during  the  day,  and  was  thought  to  be  upset  from  a  disordered  stomach. 
Friday  morning  vomited,  and  in  much  pain  ;  bowels  acted. slightly  ;  not  much  distension  ; 
child  died  same  evening,  6  P.M.  Post-mortem,  Monday,  July  29,  1889. — Some  decom- 
position ;  omentum  normal  ;  surface  of  small  intestines  intensely  injected,  most  marked 
below  umbilicus  ;  some  lymph,  not  excessive  quantity  ;  bloody  serum  between  intestines, 
a  few  ounces  in  pelvis.  Vermiform  appendix  :  external  surface  injected  ;  no  evidence  of 
past  inflammation.  Slitting  up  of  intestines  showed  them  to  be  normal,  except  the  lips  of 
the  ileo-caecal  valve,  which  were  injected  ;  the  appendix  seemed  thickened  and  osdematous, 
and  contained  some  mucus  only.  Lungs  were  normal ;  heart  also  normal ;  the  blood 
dark  and  fluid,  and  there  were  small  extravasations  of  blood  on  the  surface  of  the  heart. 
In  this  case  the  boy  died  in  two  days  from  acute  peritonitis.  No  cause  could  be  assigned, 
unless  it  resulted  from  a  blow  when  playing  with  his  brothers  the  day  before  he  was  taken 
ill.     There  was  no  bruising  of  the  abdominal  wall. 

In  the  following  case  the  symptoms  closely  resembled  acute  obstruction 
of  the  bowels  from  strangulation  : 

Acute  General  Perito?iitis. — John  C. ,  aged  g  years,  was  healthy  up  to  February  9, 
when  he  was  injured  by  a  blow  in  the  abdomen  ;  but  the  injur)'  does  not  seem  to  have 
been  very  severe.  He  complained  of  pain  in  the  belly,  and  vomited  the  same  evening. 
He  continued  to  vomit  five  or  six  times  a  day  till  his  admission  to  hospital  (under 
Dr.  Hutton)  on  the  fifth  day  of  his  illness.  He  had  passed  nothing  per  rectum  except  a 
small  stool  after  an  enema,  and  it  was  supposed  he  was  suffering  from  an  intussusception. 
On  admission  his  face  was  flushed,  the  eyes  sunken  ;  the  abdomen  was  tightly  distended, 
the  coils  of  intestines  being  plainly  seen.  He  complained  of  paroxysms  of  pain  in  the 
abdomen.  He  vomited  faecal  matter  shortly  after  admission  ;  there  was  pain  on  deep  pal- 
pation in  the  right  ihac  fossa,  but  no  marked  tenderness.  Full  doses  of  opium  were  given. 
The  next  day  (the  sixth  of  his  illness)  it  was  thought  advisable  to  make  an  exploratory 
opening  into  the  abdomen  (which  was  done  by  Mr.  Wright)  ;  the  intestines  were  deeply 
coloured,  and  matted  together  with  lymph  ;  no  constricting  band  or  invagination  was  de- 
tected ;  the  wound  was  closed  and  a  drainage  tube  inserted.  The  boy  gradually  sank,  and 
died  suddenly  the  next  day.  At  the  post-mortem  a  general  acute  peritonitis  was  found  ;  no 
cause  for  it  was  made  out  after  a  careful  search. 

In  the  light  of  the  ^Jf^jZ-wz^r/^OT  examination,  it  would  seem  that  saline 
purgatives  or  purgative  doses  of  calomel  would  have  been  worth  trying  in 
the  above  cases. 

In  the  following  case  the  peritonitis  was  secondary,  occurring  in  the 
course  of  scarlatinal  nephritis  : 

Acute  Nephritis  :  Peritonitis. — Sarah  W. ,  aged  eight  years,  was  attacked  with  scarlet 
fever,  the  initial  symptoms  being  vomiting,  high  fever,  and  rash.     She  was  admitted  to 


Acute  Peritonitis  12 1 

hospital  on  the  third  day.  The  tonsils  were  sloughj'  ;  there  was  much  glandular  enlarge- 
ment and  high  fever.  The  temperature  varied  from  loo'^  to  ioi'6°  F".  till  the  twelfth  day, 
when  it  reached  io26°  F. ,  and  a  trace  of  albumen  appeared  in  the  urine.  On  the  thir- 
teenth day  the  temperature  was  104°  Y.,  and  only  two  hundred  and  fifty  cubic  centimetres 
of  urine  were  passed.  From  the  fourteenth  to  the  sixteenth  day  the  urine  passed  was  only 
from  seventy  to  one  hundred  cubic  centimetres  daily ;  urine  contained  fibrinous  and  epi- 
thelial casts.  Eighteenth  day,  vomiting,  temperature  103°  Y.  ;  only  seventy  cubic  centi- 
metres of  urine.  Nineteenth  day,  no  urine  passed  ;  severe  abdominal  pain,  respirations 
shallow  and  thoracic,  abdomen  distended  and  tense.  Twentieth  day,  temperature  98^  to 
99°  F. ,  patient  collapsed.  Twenty-first  day,  death.  At  the  autopsy  a  general  sero-purulent 
peritonitis  was  found  ;   pleurisy  of  left  lung  ;  acute  glomerular  nephritis. 

In  the  following  case  the  cause  of  the  peritonitis  was  doubtful,  but  there 
is  no  doubt  it  was  very  extensive,  and  it  is  a  good  illustration  of  the  value  of 
operation  even  in  extreme  cases  of  purulent  peritonitis.  This  boy  was  dusky 
and  so  ill  that  we  hesitated  to  operate  at  all. 

Acute  Purulent  Peritonitis :  Operation,  Recovery. — Fred  A.,  aged  125.  Si.\  weeks 
before  admission  was  kicked  by  a  horse  in  the  right  side  of  the  abdomen.  He  was 
apparently  not  much  hurt,  and  was  allowed  by  his  doctor  to  get  up  on  the  following  day. 
Five  weeks  after  the  accident,  on  May  27,  1894,  he  had  slight  abdominal  pain,  supposed 
to  be  due  to  eating  cucumber.  Vomiting  and  pain  soon  followed,  and  tenderness  in  the 
right  iliac  fossa  a  day  or  two  later.  The  pain  spread  upwards,  vomiting  increased,  and 
extreme  tenderness  appeared  in  the  left  hypochondrium,  with  collapse.  He  was  admitted 
on  June  4.  At  that  time  he  looked  very  ill ;  anxious  face  ;  pulse  small ;  abdomen  full, 
moves  very  little  with  respiration  ;  legs  moved  freely  ;  abdominal  walls  rigid,  tenderness 
most  marked  on  left  side  ;  nothing  specially  to  be  felt  on  right  side.  A  few  hours  later, 
face  dusky  and  blue ;  rectal  examination  revealed  greater  resistance  on  the  left  side  than 
on  the  right.  The  abdomen  was  opened  in  the  middle  line  below  the  umbihcus,  and  a 
large  quantity  of  faecal  pus  escaped.  The  abscess  filled  up  the  left  iliac  fossa,  and 
appeared  circumscribed,  but  there  was  resistance  in  the  right  side  also.  He  gradually 
improved  ;  the  quantity  of  pus  escaping  from  the  tube  and  its  foetor  lessened,  and  though 
for  some  time  there  was  tenderness  in  the  right  iliac  region,  he  steadily  got  well,  and  was 
heard  of  in  good  health  four  or  five  months  later. 

Diagnosis. — A  pleurisy  of  the  base  of  one  or  other  of  the  lungs  is  often 
mistaken  for  peritonitis,  as  the  sharp  stabbing  pain  is  apt  to  be  referred  to  the 
abdomen  where  the  intercostal  nerves  terminate.  In  some  cases,  especially 
if  the  pleurisy  involve  the  diaphragm,  the  similarity  to  peritonitis  may  be 
great,  and  it  is  common  to  find  that  hot  fomentations  or  mustard  poultices 
have  been  placed  upon  the  abdomen  by  the  friends  under  the  idea  that  there  is 
peritonitis.  Where  pleurisy  exists  there  is  no  real  tenderness  of  the  abdomen 
on  pressure,  and  the  physical  signs  of  pleurisy  or  pleuro-pneumonia  will  be 
detected  in  the  chest.  An  attack  of  colic  is  not  often  likely  to  be  mistaken 
for  peritonitis  ;  in  the  former  there  is  pain  and  distension  of  the  abdomen,  but 
no  tenderness  or  elevated  temperature.  An  intussusception  may  be  mistaken 
for  peritonitis  ;  but  the  attack  of  pain  is  more  sudden  in  the  former,  and 
there  is  not  often  much  tenderness  ;  the  detection  of  an  elongated  tumour 
would  usually  decide  the  diagnosis  ;  both  an  intussusception  and  also 
peritonitis  maybe  present.  Acute  peritonitis  is  apt  to  be  mistaken  for  acute 
obstruction  of  the  bowels,  such  as  results  from  the  constriction  of  a  knuckle 
of  bowel  by  a  band.  The  distension  of  the  intestines  with  flatus,  the  vomit- 
ing of  sour-smelling  intestinal  contents,  as  well  as  complete  obstruction  to 


122  Diseases  of  the  Digestive  System 

the  passage  of  wind,  may  be  present  in  both  ;  there  may  be  Uttle  tender- 
ness, and  but  sHght  or  no  fever.  The  diagnosis  may  be  very  difificult  or 
impossible,  though  the  history  of  the  case,  the  absence  of  faecal  vomiting, 
and  the  less  complete  obstruction  to  the  passage  of  both  flatus  and  faeces  in 
the  case  of  peritonitis,  will  usually  help  the  decision.  It  is  hardly  necessary 
to  add  that  it  is  only  in  some  cases  of  acute  peritonitis  that  the  difficulty  exists, 
as  usually  the  pain,  tenderness,  and  distension  of  the  intestines  are  diagnostic 
of  peritonitis. 

Morbid  Anatomy. — The  tendency  to  pus  formation,  which  all  inflamma- 
tions in  children  exhibit,  is  noticeable  in  peritonitis,  as  in  acute  cases  the 
fluid  found  in  the  peritoneum  is  thick  and  turbid,  or  it  may  rank  as  pure  pus. 
The  amount  of  lymph  and  fluid  varies  in  different  cases  ;  pus  or  turbid 
serum  will  often  be  found  in  meshes  of  lymph  between  the  coils  of  intestines, 
a  larger  collection  being  present  in  the  pelvis.  In  all  cases  of  apparent 
idiopathic  peritonitis,  a  careful  search  should  be  made  for  a  local  starting 
point  ;  the  caecum,  mesenteric,  and  retro-peritoneal  glands  being  carefully 
examined. 

Prognosis. — This  is  always  grave  ;  the  more  acute  the  symptoms,  the 
more  rapidly  the  fatal  result  occui's.  The  prognosis  in  any  case  mostly 
depends  on  the  diagnosis,  for,  if  acute  general  peritonitis  is  present,  a  fatal 
result  is  almost  certain. 

PeritypMitis.  iippenaicular  Peritonitis. —  Instead  of  a  general  peri- 
tonitis taking  place,  a  local  inflammatory  action  may  be  set  up,  which  results 
in  simple  inflammatory  induration  going  on  in  many  cases  to  the  formation 
of  an  abscess,  or  a  general  peritonitis  may  supervene.  The  commonest 
local  peritonitis  is  a  typhlo-peritonitis  or  perityphlitis  as  it  is  generally 
called.  The  caecum  is  especially  apt  to  be  the  seat  of  irritation,  a  peculiarity 
which  it  doubtless  owes  to  its  being  a  cul-de-sac,  in  which  foreign  bodies  or 
impacted  faeces  are  apt  to  lodge,  and  give  rise  to  various  forms  of  trouble. 
Pins,  fish  bones,  cherry  stones,  are  apt  to  lodge  in  the  caecum,  and  occasionally 
gravitate  into  the  caecal  appendix,  and  though  the  latter  is  not  normally 
traversed  by  the  intestinal  contents  as  they  pass  downwards,  concretions  are 
likely  to  form  from  the  deposition  of  fcecal  particles,  inspissated  mucus, 
phosphates  of  lime,  and  other  salts.  As  a  result,  ulceration  of  the  caecum  or 
appendix  is  very  apt  to  take  place,  and  a  perforation  to  be  followed  by  a 
local  or  general  peritonitis.  In  the  majority  of  cases  it  is  now  well  recognised 
that  in  most  cases  the  mischief  begins  in  an  inflammation  of  the  appendix 
due  either  to  retained  secretion  or  to  the  presence  of  some  solid  matter 
which  may  be  formed  in  the  appendix,  or  enter  it  from  the  bowel  ;  occasion- 
ally there  is  tubercular  disease  of  the  follicles  of  the  appendix,  but  this 
would  give  rise  to  more  chronic  symptoms,  Rheumatic  and  other  forms  of 
appendicitis  are  described,  but  the  name  is  of  doubtful  value.  The  appendix 
from  its  richness  in  adenoid  tissue  may  be  looked  upon  as  the  tonsil  of  the 
large  intestine,  and  like  the  faucial  tonsils  may  become  inflamed  as  a  result 
of  direct  infection  with  poisonous  matters.  The  symptoms  presented  by 
perityphlitis  in  the  child  resemible  those  present  in  the  adult.  The  attack 
may  begin  with  diarrhoea  and  perhaps  vomiting,  with  more  or  less  obscure 
pain  and  tenderness  in  the  abdomen,  and  feverishness.  It  is  often  extremely 
difficult  to  localise  the  pain  and  tenderness  in  a  small  child,  and  it  may  be 


Perityphlitis     Appoidiculdr  Peritonitis  123 

quite  impossible  at  first  to  refer  llie  tenderness  to  any  one  spot,  especial!)- 
as  the  abdominal  muscles  are  apt  to  be  rigidly  contracted,  and  the  child 
cries  directly  it  is  touched.  The  state  of  the  bowels  varies  ;  sometimes  they 
are  relaxed,  at  other  limes  obstinately  constipated.  In  the  course  of  a  few 
days,  during  which  time  the  pyrexia  continues,  if  a  satisfactory  examination 
can  be  made,  more  or  less  resistance  may  be  detected  by  palpation  in  the 
iliac  or  lumbar  region,  and  a  dulness  on  gentle  percussion,  though  this  may 
be  masked  by  the  distension  of  the  small  intestines.  The  patient  may  now, 
especially  if  he  has  been  judiciously  treated,  gradually  improve,  and  all  pain 
and  tenderness  disappear  in  the  course  of  a  week  or  two.  On  the  other  hand, 
the  tenderness  may  increase,  a  distinct  hardness  and  induration  may  be  felt 
in  the  right  iliac  region,  the  right  leg  is  drawn  up,  and  the  child  cries  with 
pain  if  it  is  moved.  The  subsequent  course  of  the  attack  is  uncertain:  there 
may  be  a  gradual  subsidence  of  all  the  symptoms,  or  if  the  abscess  is  not 
opened,  the  hectic  fever  may  continue,  the  child  gradually  emaciate,  while 
the  pus  which  has  been  formed  is  making  its  way  to  the  surface,  and  the 
abscess  may  point  in  the  iHac  region,  may  discharge  into  the  bowel,  or,  in 
rare  cases,  into  the  bladder  or  vagina.  Fasces  may  be  found  in  the  pus  dis- 
charging from  the  iliac  abscess,  and  a  faical  fistula  result,  or  all  the  signs  of 
general  peritonitis,  abdominal  distension,  extreme  tenderness,  and  collapse, 
may  come  on. 

The  diagnosis  of  perityphlitis  is  often  by  no  means  easy,  and  yet  of 
much  importance,  inasmuch  as  a  mistake  in  diagnosis  may  readily  cost  a 
life.  In  the  early  stages,  the  diseases  most  likely  to  be  confounded  with  it, 
especially  in  small  children,  are  coprostasis  or  accumulation  of  hardened 
ficces  in  the  caecum,  and  invagination  of  the  intestines  ;  in  a  later  stage, 
when  the  patient  is  seen  for  the  first  time  after  an  abscess  has  formed,  there 
may  be  uncertainty  as  to  the  source  of  the  pus.  Children  who  have  just  begun 
to  run  alone,  and  are  able  to  make  frequent  excursions  into  the  kitchen,  or 
who  are  fed  on  all  sorts  of  indigestible  food,  are  especially  liable  to  siififer 
from  an  accumulation  of  hardened  f;Eces  in  the  ctecum,  which  may  set  up 
more  or  les^  irritation,  and  give  rise  to  symptoms  exceedingly  like  those  of 
a  perityphlitis.  There  is  distension  of  the  abdomen,  colicky  pains,  vomiting, 
slight  feverishness,  constipation,  or,  on  the  other  hand,  diarrhoea  ;  and  it 
must  be  borne  in  mind  that  looseness  of  the  bowels  is  quite  compatible  with 
a  loaded  ctecum  or  large  intestine.  It  may  be  possible  to  detect  a  faecal 
tumour  in  the  right  lumbar  region.  The  diagnosis  in  a  fretful  spoilt  child 
may  be  exceedingly  difficult,  but  the  symiDtoms  of  impacted  faeces  in  the 
Ciecum  will  be  rather  those  of  colic,  the  pain  coming  on  spasmodically,  with 
no  pain  or  tenderness  in  the  intervals  ;  while  in  perityphlitis  the  pain  will 
be  constant,  and  the  tenderness  on  deep  pressure  unmistakable.  In  any 
gi\'en  case  it  is  far  better  to  err  on  the  safe  side,  and  to  mistake  colic  for 
typhlo-peritonitis,  than  to  fall  into  the  more  serious  error  of  overtreating  a 
child  suffering  from  a  local  peritonitis  with  purgatives  and  enemas.  An 
ileo-ciecal  invagination  with  its  symptoms  of  sudden  obstruction  of  the 
bowel  is  probably  not  very  likely  to  be  mistaken  for  perityphlitis  ;  the 
sudden  attack  in  an  infant  in  perfect  health,  the  colicky  pains,  the  straining, 
and  passage  of  blood  and  mucus,  and  the  presence  of  a  painless  tumour, 
would   in  most  cases  prevent  a  mistaken  diagnosis.     To  make  a   diagnosis, 


124  Diseases  of  the  Digestive  System 

an  examination  under  chloroform  may  be  necessary  with  the  finger  in  the 
rectum. 

The  value  of  rectal  examination  was  well  shown  in  a  patient  of  Dr. 
Denholm's,  in  whom,  with  signs  of  peritonitis,  no  evidence  at  all  conclusive 
could  be  found  of  the  locality  of  the  mischief  till  an  examination  of  the 
rectum  was  made  while  the  child  was  under  chloroform.  A  mass  was  then 
felt  filling  up  the  pelvis  on  the  right  side,  and  a  diagnosis  of  appendicular 
peritonitis,  with  the  appendix  hanging  over  the  brim  of  the  true  pelvis,  was 
arrived  at.  An  incision  as  for  ligature  of  the  external  iliac  artery  allowed 
the  peritoneum  to  be  turned  forward,  and  the  abscess  was  with  some 
difficulty  reached,  and  opened  without  soiling  the  general  cavity  of  the 
peritoneum,  which  must  have  been  inevitably  done  if  the  abscess  had  been 
sought  by  the  usual  route.  The  appendix  was  felt  lying  in  the  abscess 
cavity.     The  child  did  perfectly  well. 

Peritoneal  ilbseess.  Intestinal  Fistula. — Apart  from  the  suppuration 
which  is  liable  to  take  place  as  the  result  of  a  typhlo-peritonitis,  other  abscesses 
are  liable  to  occur  in  the  abdomen,  due  in  the  majority  of  cases  to  tubercular 
disease  in  the  mesenteric,  retro-peritoneal,  or  rectal  glands.  Local  abscesses 
may  also  occur  as  the  result  of  a  blow  or  following  a  perforation  of  the  intestine 
in  typhoid  fever  or  tubercular  ulceration.  As  an  instance  of  a  glandular 
abscess  in  the  abdomen  the  following  case  may  be  taken  as  an  example  : 

Abdominal  Abscess  :  Discharge  of  Pus  at  Umbilicus. — A  girl  of  seven  years  of  age  was 
admitted  to  hospital,  having  suffered  for  thirteen  days  with  pain  in  the  abdomen,  fever, 
and  vomiting.  On  admission  there  was  some  dullness  below  the  umbilicus  and  great 
tenderness ;  the  temperature  varied  from  ioo°  to  102°.  The  day  after  the  lunbiHcus 
became  prominent  and  the  skin  red  ;  it  gave  way  and  pure  pus  was  discharged.  The 
wound  continued  to  discharge  for  some  time — on  one  occasion  a  cheesy  mass  was  removed 
from  the  sinus,  followed  by  a  fresh  discharge  of  pus ;  the  sinus  finally  closed  on  the  forty- 
eighth  day.  At  the  end  of  ten  weeks  the  girl  was  fat  and  strong  ;  there  was  some  indura- 
tion, but  no  pain  or  tenderness  below  the  umbilicus.  On  one  occasion  there  was  some 
pus  in  a  stool. 

Abdominal  Abscess:  Operation. — A  girl  of  12  years  was  seized  with  vomiting,  fever, 
and  abdominal  tenderness  ;  sordes  formed  on  the  teeth,  the  tongue  was  brown,  there  was 
extreme  distension  of  the  abdomen  ;  the  bowels  did  not  act,  and  no  flatus  was  passed. 
On  the  eighth  day  there  was  a  crisis,  the  temperature  fell  to  normal  and  the  pulse  from 
120  to  80.  At  the  same  time  a  slight  prominence  was  noted  just  below  and  to  right  of 
umbilicus  ;  this  was  cut  down  upon  and  2  oz.  of  faecal  pus  escaped.  The  recovery  was 
uninterrupted. 

Tttbercitlar  Abscess. — In  an  infant,  seen  with  Dr.  Noble,  of  Kendal,  it  was  noticed  a  week 
or  two  after  birth  that  the  abdomen  was  more  rounded  and  distended  than  usual.  When 
five  weeks  old  the  abdomen  was  intensely  distended,  shiny,  with  enlarged  veins  on  the 
surface,  and  with  redness  and  protrusion  of  the  umbilicus  ;  the  abdomen  was  resonant  all 
over,  and  nothing  could  be  felt  on  palpation.  A  few  days  later  the  skin  at  the  umbilicus 
gave  way,  and  pus  discharged  freely.  The  infant  a  few  days  after  died  in  convulsions. 
A  large  abscess  cavity  was  found  at  the  autopsy,  and  caseous  mesenteric  glands.  Apparently 
this  was  a  case  of  congenital  tuberculosis. 

In  other  cases,  with  somewhat  similar  but  more  chronic  symptoms,  there 
has  been  evidence  that  an  abscess  had  formed,  probably  in  a  mesenteric 
gland,  and  had  opened  into  the  bowel,  pus  being  discharged  with  diarrhoeal 
stools.  Other  cases  occur  which  are  by  no  means  so  satisfactory  in  their 
terminations,  being  in  many  instances  associated  with  a  chronic  tubercular 


Peritoneal  Abscess    - Intesti)tal  I'ishila  125 

peritonitis  or  mesenteric  disease.  There  are  symptoms  of  abdominal 
trouble,  attacks  of  vomiting  and  diarrhoea,  hectic  fever  and  wasting,  an 
induration  and  at  length  an  inflammatory  blush  around  the  umbilicus  ;  the 
latter  becomes  perforated  and  pus  discharges.  Frequently,  sooner  or  later, 
the  discharge  becomes  faecal  from  the  presence  of  intestinal  contents,  a  fistu- 
lous opening  having  become  established.  In  the  majority  of  such  cases  the 
abscess  apparently  originates  in  a  mesenteric  gland,  an  abscess  cavity  is 
formed  which  is  surrounded  by  coils  of  small  intestine  matted  together,  and 
the  abscess  opens  both  at  the  umbilicus  and  into  the  bowel  in  some  part  of 
its  course  ;  but  as  such  cases  are  mostly  chronic,  opportunities  for  post- 
mortem examinations  are  not  frequent,  and  when  an  opportunity  presents 
itself  there  is  so  much  matting  of  parts  that  it  is  difficult  to  make  out  the 
origin  of  the  abscess. 

The  following  case  illustrates  this  difficulty  : 

Abdominal  Abscess :  Fcscal  Fistula. — A  girl  of  four  years  of  age  was  in  hospital,  June 
1879,  with  obscure  abdominal  symptoms,  hectic  and  wasting  ;  in  the  following  December 
she  was  admitted  with  a  sinus  at  the  umbilicus,  discharging  pus  and  intestinal  contents, 
an  abscess  having  broken  ten  weeks  before.  The  fistulous  opening  continued  to  discharge 
pus  and  liquid  yellow  gaseous  faeces  till  her  death  in  October  1880.  At  the  post-mortem 
the  liver  and  spleen  were  lardaceous.  The  umbilical  sinus  was  connected  w'th  an  abscess 
cavity  containing  one  or  two  ounces  of  pus  and  faeces,  and  surrounded  on  all  sides  by 
intestines  matted  together  ;  this  cavity  communicated  with  the  ileum  a  foot  and  a  half 
above  the  caecum  by  two  openings  large  enough  to  admit  a  little  finger.  On  the  peritoneal 
surface  of  the  small  intestines  were  cretaceous  nodules,  apparently  the  remains  of  a  past 
tubercular  peritonitis.  In  the  ileum  were  many  cicatrices  and  calcaieous  remains  of  old 
ulcers  and  cheesy  solitary  glands. 

In  this  case  the  perforation  of  tubercular  ulcers  or  the  suppuration  of 
mesenteric  glands  had  been  the  cause  of  the  abscess  and  fistulous  openings. 
In  several  cases  coming  under  notice  the  fistulous  openings  have  closed  up 
permanently,  one  after  discharging  for  seven  months,  and  in  some  others 
the  fistulous  opening  has  closed,  but  the  patient  died  of  general  tuberculosis. 

Tt-eat/nent. — The  treatment  of  peritonitis  will  naturally  depend  upon  its 
cause,  and  unfortunately  we  are  constantly  in  doubt  about  this,  or  indeed  if 
peritonitis  exists  at  all,  especially  in  the  early  stages  of  some  abdominal  case. 
In  any  case  of  peritonitis  or  doubtful  case,  we  must  feed  with  the  greatest 
care,  allowing  only  small  quantities  of  readily  absorbed  forms  of  nutriment, 
such  as  Brand's  essence  or  bovril,  and  only  small  quantities  of  fluid  of 
any  sort.  These  may  be  given  iced.  If  the  vomiting  is  severe  and  continu- 
ous, all  fluid  must  be  withheld  by  the  mouth  and  rectal  feeding  adopted. 
Hot  fomentations  applied  to  the  abdomen  relieve  pain  and  comfort  the 
patient.  Some  prefer  to  apply  an  ice-bag,  but  it  is  not  as  comforting  as 
warmth  and  heat.  Opium  given  with  a  free  hand  has  been  our  sheet-anchor 
hitherto  in  the  treatment  of  peritonitis,  but  of  late  years  there  has  been  a 
considerable  revulsion  of  feeling,  especially  on  the  part  of  abdominal  surgeons. 
There  can  be  no  doubt  of  its  value  in  relieving  pain  and  checking  the  intense 
griping  which  often  occurs,  but  on  the  other  hand  it  masks  the  symptoms 
and  makes  diagnosis  more  difficult,  helps  to  paralyse  the  intestinal  wal^s  and 
so  lock  up  the  intestinal  contents  and  favour  the  formation  of  toxines  in  the 
stagnant  fluids  in  the  bowel.     In  suitable  cases  there  can  be  no  doubt  that 


126  Diseases  of  the  Digestive  System 

saline  purgatives  are  of  the  greatest  value  in  clearing  out  the  bowels  and 
getting  rid  of  flatus.  There  can  hardly  be  a  doubt  that  in  past  times  we 
have  been  too  much  afraid  of  purgatives,  and  have  erred  too  much  on  the 
side  of  keeping  the  bowels  at  rest  and  thus  locking  up  their  contents.  In 
any  case  of  obstruction  of  the  bowels  from  a  constricting  band  or  an  invagi- 
nation, it  is  clear  that  purgatives  can  do  nothing  but  harm,  but  on  the  other 
hand,  in  a  case  of  general  peritonitis  secondary  to  enteritis  or  intestinal  infec- 
tion, they  afford  the  best  chance  for  the  patient.  In  appendicular  peritonitis 
we  have  in  the  past  been  too  much  dominated  by  the  '  cherry-stone  '  in  the 
appendix  and  the  supposed  necessity  of  keeping  the  parts  absolutely  at  rest 
to  use  anything  but  opium  or  its  derivatives.  In  any  case  seen  early  in  which 
we  can  exclude  invagination  or  strangulation  of  the  bowel,  we  should  cer- 
tainly give  a  purgative,  preference  being  given  to  salines  or  calomel  to  secure 
a  free  evacuation  of  the  intestinal  contents;  An  enema  containing  sweet  oil 
and  turpentine  should  be  given  to  clear  away  the  contents  of  the  large 
bowel  ;  it  is  seldom  that  an  efficient  enema  is  given  by  the  patient's  friends, 
and  it  is  better  for  the  medical  man  to  see  for  himself  that  it  is  done  tho- 
roughly and  efficiently.  Nepenthe  or  morphia  should  be  given  to  relieve  pain, 
and  is  best  given  in  association  with  belladonna.  The  amount  to  be  given 
and  further  treatment  of  the  case  must  depend  upon  the  decision  come  to  as 
regards  operative  interference. 

Since  acute  purulent  peritonitis  is  practically  certainly  fatal  if  it  becomes 
generalised,  it  is  of  the  utmost  importance  to  provide  an  outlet  for  a  localised 
abscess  rather  than  allow  it  to  go  on  and  rupture  into  the  general  peritoneal 
cavity.  Hence,  as  soon  as  it  is  clear  that  a  local  form  of  inflammation  is  not 
subsiding  under  medical  treatment,  the  safest  course  is  to  carefully  cut  down 
upon  and  let  out  the  pus.  In  perityphlitic  abscess  ('appendicular  perito- 
nitis '),  when  with  fever  there  is  local  pain,  tenderness  and  induration  and 
drawing  up  of  the  leg,  an  incision  should  be  made  just  internal  to  the  anterior 
superior  spine  of  the  ilium  and  the  successive  muscular  layers  divided  until 
the  neighbourhood  of  the  abscess  is  made  clear  either  by  the  sense  of  fluc- 
tuation or  by  the  oedematous  condition  of  the  tissues  :  a  director  is  then 
thrust  in  the  direction  of  the  suspected  cavity,  and  if  pus  appears  the  opening 
is  enlarged  with  dressing  forceps  and  the  cavity  drained  and  treated  on 
ordinary  principles  (antiseptics  being  used  unless  the  pus  is  foul).  There  is 
little  danger  in  such  an  operation  ;  even  if  no  abscess  is  met  with  and  the 
peritoneal  cavity  is  opened,  no  ill  result  is  likely  to  follow,  while  the  danger 
of  rupture  of  an  abscess  into  the  general  peritoneal  cavity  is  very  great. 
Local  peritoneal  abscess  elsewhere  is  much  more  uncommon,  though  it  may 
be  met  with  on  the  left  side  (perisigmoid  abscess),  and  this  can  be  made  out 
at  times  by  rectal  examination.  The  treatment  is  that  of  the  perityphlitic 
condition.  It  is  of  little  importance  in  such  cases  to  make  out  whether  the 
abscess  is  really  a  local  peritonitis  or  a  collection  of  matter  in  the  cellular 
tissue  outside  the  peritoneum,  since,  if  peritoneal,  it  is  usually  completely 
shut  off  by  adhesions  from  the  general  cavity,  and  there  is  no  fear  of  pus 
flowing  from  the  wound  into  the  peritoneum.  Local  abscesses  elsewhere 
must  be  treated  on  similar  principles.  Should  a  general  purulent  peritonitis 
already  exist,  the  question  of  treatment  is  more  uncertain  and  the  prospect 
far  less  hopeful  ;  there  is,  however,  little  doubt  that  the  right  course  is  to 


Peritoneal  Abscess — Intestinal  Fistula  127 

open  the  abdomen,  wash  it  out  with  some  imirritating  antiseptic,  such  as 
boracic  lotion,  and  drain  the  peritoneum.  Should  there  be  general  fa;cal  ex- 
travasation from  perforation  of  the  ca^cal  appendix,  or  from  a  typhoid  ulcer, 
the  case  must  be  looked  upon  as  well-nigh  desperate  ;  the  attempt,  however, 
may  be  made  to  expose  the  perforation,  suture  the  intestine,  and  in  the  case 
of  the  appendix  remove  it  and  close  the  end.  Cases  of  iliac  abscess  of 
uncertain  origin  are  not  uncommon,  and  operation  is  almost  always  success- 
ful, and  though  it  may  be  said  that  these  are  a  different  class  altogether  from 
the  local  peritonitis  group,  it  is  difficult  to  distinguish  between  the  two,  and 
there  is  certainly  a  risk  of  perforation  into  the  peritoneum.  In  appendicular 
abscess  nothing  more  should  be  done  than  simple  incision  and  drainage  ; 
no  attempt  should  be  made  to  remove  the  appendix  or  look  for  a  cause  of  the 
suppuration  except  that  the  finger  may  be  gently  passed  into  the  abscess  and 
any  foreign  body  removed.  We  have  several  times  found  a  faecal  concre- 
tion lying  loose  in  one  of  these  cavities.  The  greatest  care  must  be  taken 
not  to  break  down  the  wall  of  adhesion  round  the  abscess.  The  opening  of 
a  local  appendicular  abscess  is  in  our  experience  almost  always  a.  successful 
operation,  but  it  is  of  course  far  otherwise  if  the  suppuration  has  been  from 
the  first,  or  has  been  allowed  to  become  general  ;  in  such  a  case,  too,  a  full 
search  must  be  made  for  the  source  of  the  trouble,  and  an  attempt  made  to 
remove  it,  whether  by  ligature  and  excision  of  a  perforated  appendix,  or  such 
other  means  as  the  particular  case  may  require. 

In  cases  of  recurrent  'appendicular  peritonitis'  removal  of  the  appendix 
is  undoubtedly  the  proper  course  to  pursue,  since  life  is  in  constant  danger 
as  long  as  the  source  of  the  mischief  remains.  Recurrent  appendicitis,  so 
common  in  young  adult  life,  is  not  very  frequently  seen  in  children  ;  in  them 
the  more  delicate  tissues  seem  to  suppurate  more  readily,  and  abscess  is  the 
rule.  We  cannot  emphasise  too  strongly  the  desirability  of  early  operation 
in  these  cases.  If  with  a  high  temperature  a  child  has  a  distinct  induration 
or  sense  of  resistance  in  the  right  iliac  region,  the  sooner  the  swelling  is 
explored  the  better.  We  have  never  regretted  operating,  and  never  failed  to 
find  pus  in. these  cases,  even  where  its  presence  seemed  doubtful.  We  feel 
sure  from  observation  that  in  many  instances  in  which  it  has  been  supposed 
that '  resolution  '  took  place  there  has  really  been  an  abscess  which  discharged 
into  the  bowel. 

Iliac  Abscess. — The  occurrence  of  iliac  abscess,  right  or  left,  is  fre- 
quent in  children,  and  the  various  causes  of  such  mischief  should  be  borne  in 
mind  ;  the-principal  ones,  some  of  which  have  been  already  mentioned,  are 
caries  of  the  spine,  tubercular  disease  of  the  mesenteric  glands — in  this  case 
the  abscess  is  more  often  umbilical — disease  of  the  hip,  innominate  bones,  or 
sacro-iliac  joint,  perinephritic  abscess,  rare  in  children,  and  the  still  rarer 
cases  of  hydatid  cysts.  Empyemata,  superficial  abscesses  and  abscesses 
the  result  of  injury,  '  simple  psoitis,'  &c.  are  to  be  thought  of  in  addition  to 
those  already  described  as  resulting  from  irritation  of  the  caecum  or  appendix. 
But  besides  all  these,  it  is  common  to  find  iliac  abscesses  the  cause  of  which 
remains  obscure,  and  we  are  satisfied  that  in  many  of  these  cases  the  suppu- 
ration is  simply  due  to  inflammation  of  lumbar,  iliac,  or  pelvic  lymphatic 
glands,  just  as  cervical  abscesses  occur  from  irritation  of  the  glands  of  the 
neck.     The  source  of  irritation  is  often  doubtful,  but  is  sometimes  due  to  the 


128  Diseases  of  the  Digestive  System 

presence  of  worms  or  other  irritating  matters  in  the  bowels  ;  sometimes  to  ex- 
tension from  the  more  superficial  lymph  glands.  The  diagnosis  can  usually 
be  made  by  careful  exclusion  and  by  the  history  ;  rectal  examination  is  often 
of  much  value,  by  enabling  the  extent  and  position  of  the  abscess  to  be 
made  out,  as  well  as  sometimes  by  revealing  a  source  of  irritation.  These 
abscesses  should  be  opened  antiseptically  and  drained  in  the  usual  way  :  it 
will  often  be  found  that  they  extend  for  long  distances  upwards  or  down- 
wards into  the  pelvis.  The  limb  on  the  affected  side  should  be  steadied  by 
a  splint  or  by  extension.  The  prognosis  is  good,  provided  no  permanent 
source  of  suppuration  be  present.  Almost  every  case  that  we  have  seen 
has  recovered,  and  we  believe  this  is  largely  due  to  early  opening  of  the 
abscesses.' 

Cbronic  Peritonitis. — Chronic  peritonitis  is  a  comparatively  common 
aifection  during  childhood,  and  in  the  vast  majority  of  cases  is  tubercular. 
A  few  cases  of  chronic  non-tubercular  peritonitis  in  which  the  diagnosis  has 
been  confirmed  by  2i  post-mortem  have  been  recorded,  notably  one  by  Henoch 
which  ran  a  course  of  six  weeks  ;  at  the  post-mortem  cloudy  fluid  and  orga- 
nising lymph  were  found  in  the  peritoneal  cavity.  This  case  seems  to  have 
originated  in  a  blow.  Cases  frequently  occur  in  practice  of  chronic 
peritonitis  with  ascites,  in  which  there  is  no  evidence  of  tubercle  in  any  organ, 
and  which  completely  recover  ;  this,  however,  is  no  bar  to  the  acceptance  of 
the  belief  that  such  are  tubercular,  as  there  is  ample  post-mortem  evidence 
to  show  that  tubercles  and  lymph  on  the  surface  of  the  peritoneum  may  be- 
come cretaceous  or  be  converted  into  fibrous  tissue.  Two  forms  of  chronic 
tubercular  peritonitis  are  met  with  in  practice,  in  which  for  the  most  part  a 
well-marked  clinical  difference  exists,  one  distinguished  by  the  large  amount 
of  ascitic  fluid  and  in  which  probably  ascites  is  the  only  symptom  present, 
and  the  chronic  cicatrismg  form  in  which  there  is  induration  and  thicken- 
ing of  the  great  omentum  and  a  matting  together  of  all  the  abdominal  organs 
with  little  or  perhaps  no  fluid.  The  same  tubercular  process  is  going  on  in 
both  cases,  but  produces  in  one  a  large  amount  of  effusion,  in  the  other  less 
or  perhaps  no  fluid,  but  the  effusion  of  lymph  and  its  gradual  organisation 
and  cicatrisation. 

Ascitic  Form. — Chronic  peritonitis  is  by  far  the  most  common  cause  of 
ascites,  or  rather  dropsy  commencing  in  the  peritoneal  cavity  during  child- 
hood, while,  as  well  known,  some  form  of  portal  obstruction  is  the  commonest 
cause  in  adults.  Ascites  due  to  chronic  peritonitis  is  not  common  during 
the  first  year  of  life  ;  not  that  it  does  not  occur,  but  the  infant  dies  before  the 
chronic  stage  is  reached.  It  is  not  uncommon  during  the  second  year  of 
life,  and  occurs  with  some  frequency  up  to  and  beyond  puberty.  There  is 
generally  a  history  of  pain  in  the  abdomen  of  a  more  or  less  obscure  kind 
which  has  been  regarded  as  due  to  indigestion,  probably  also  both  feverish- 
ness  and  diarrhoea,  and  then  the  belly  begins  to  swell.  In  some  cases  the 
enlargement  of  the  abdomen  is  the  first  symptom  which  leads  the  friends  to 
think  anything  is  wrong  with  the  child.  On  examination  a  rounded  and 
distended  abdomen  is  found,  there  is  dulness  and  fluctuation  to  be  felt  in  the 
flanks  if  the  patient  is  lying  oh  his  back  ;  while  there  is  a  more  or  less  ex- 

1  For  details  of  some  of  these  cases  we  may  refer  to  a  paper  in  the  Arch,  of  Pmdiatrics, 
vol.  i.  1884,  and  to  the  Cliildrens  Hospital  Abstracts;  also  Lancet,  February  1891. 


Tubercular  Peritonitis  129 

tended  region  of  resonance  around  the  umbilicus  where  the  distended  small 
intestines  are  buoyed  up  to  the  surface.  The  fluid  may,  however,  be  localised 
by  adhesions.  The  abdomen  is  often  greatly  distended,  the  skin  tense  and 
shining,  the  abdominal  veins  enlarged  and  tortuous,  and  in  young  children 
the  skin  at  the  umbilicus  is  protruded,  and  contains  fluid  which  can  be  pressed 
back  into  the  abdomen.  There  is  usually  complete  absence  of  pain  and  ten- 
derness, the  disease  is  frequently  feverless  during  the  greater  part  of  its 
course,  and  the  patient  looks  rather  as  if  he  were  suffering  from  ascites  due 
to  some  obstruction  in  the  portal  system.  The  course  of  the  disease  is 
essentially  chronic,  and  recovery  frequently  takes  place  if  the  tubercular 
disease  remains  local. 

Thus  in  one  case  a  girl,  aged  13  years,  who  was  in  hospital  for  some 
five  months,  and  from  whom  eight  to  nine  pints  of  ascitic  fluid  were  re- 
moved through  one  of  Southey's  canulas,  completely  recovered,  and  was 
four  years  after  a  strong  girl,  supporting  her  mother  and  family  by  her  work. 
In  many  similar  cases  we  have  seen  recovery  take  place  ;  one  suffered  from 
a  tubercular  testis  which  discharged  through  the  scrotum  and  healed.  On 
the  other  hand,  such  children  are  apt  to  be  carried  off  by  a  tubercular  menin- 
gitis, or  the  mesenteric  glands  become  cheesy,  or  a  tuberculosis  of  the  lungs 
takes  place.  In  any  case  it  will,  of  course,  be  necessary  to  carefully  examine 
the  lungs,  and  a  long-continued  hectic  and  wasting  would  suggest  a  more 
extended  area  of  tuberculosis.  In  cases  which  end  in  recovery  there  is 
probably  a  matting  together  of  the  intestines,  and  frequently  more  or  less 
induration  may  be  felt  about  the  great  omentum  or  ciECum.  In  cases  which 
are  of  long  standing  it  occasionally  happens  that  a  perihepatitis  with  more 
or  less  cirrhosis  of  the  liver  takes  place.  This  was  the  case  in  a  boy  of  3^^ 
years  who  was  admitted  to  hospital  under  the  care  of  Dr.  Hutton,  with  ascites, 
cedema  of  the  feet  and  ankles,  jaundice  and  enlarged  Xw^x  ;  at  \h& post-mortem 
the  liver  weighed  15  oz.,  the  capsule  was  thickened  and  the  surface  was 
irregular  and  granular  ;  on  section  there  was  a  great  excess  of  fibrous  tissue, 
old  and  recent  peritonitis  and  tuberculosis  of  the  lungs. 

Cicatrisittg  Form. — In  many  cases  of  tubercular  peritonitis  there  is  little 
or  no  ascites  from  first  to  last,  but  lymph  is  effused  on  the  surface  of  the 
peritoneal  covering  of  various  organs,  and  if  the  patient  live  long  enough, 
fibrous  adhesions  are  formed.  On  the  post-mortem  table,  local  or  general 
peritonitis  is  frequently  found  in  children  dying  of  tuberculosis  ;  thus,  out  of 
105  post-mortems  oi  \.\i!at.xcv\'aiX  children  made  during  the  four  years  1882-85, 
there  was  peritonitis  in  38,  though  in  comparatively  few  of  these  was  the 
peritonitis  an  early  and  important  lesion.  While  this  form  of  peritonitis  is 
mostly  chronic,  yet  some  cases  run  a  more  active  and  subacute  course.  The 
early  symptoms  are  pain  in  the  abdomen,  usually  referred  to  the  umbilicus, 
often  attacks  of  sickness  and  diarrhoea,  hectic,  and  the  presence  of  induration 
or  irregular-shaped  masses  felt  through  the  abdominal  walls.  The  amount 
of  tenderness  on  pressure  differs  greatly  ;  it  is  most  marked  in  the  acuter 
cases,  and  absent  in  the  chronic  ones.  But  in  cases  wasted  and  exhausted 
by  acute  disease,  even  a  purulent  peritonitis  may  be  present  without 
any  pain  or  tenderness.  The  state  of  the  abdomen  varies,  it  is  sometimes 
distended  with  gas,  at  other  times  more  or  less  retracted;  often  no  distinct 
tumour  can  be  felt,  but  on  very  gentle  percussion  a  distinct  loss  of  resonance, 

K 


130  Diseases  of  the  Digestive  System 

or  a  muffled  resonance,  maj^  be  detected  over  the  umbilical  region  in  conse- 
quence of  the  thickening  and  induration  of  the  great  omentum,  or  a  resist- 
ance may  be  felt  on  palpation,  or  hard  irregular  tumours  can  be  detected, 
the  result  of  matting  together  of  the  omentum  or  intestines.  Hectic  fever  is 
mostly  present,  the  temperature  rising  to  102°  or  103°  at  night  and  falling  to 
normal  in  the  morning,  and  more  or  less  general  wasting  of  the  body  ensues  ; 
but  the  amount  of  fe-\er  and  wasting  present  will  depend  upon  the  extent  to 
which  the  mesenteric  glands  and  thoracic  viscera  are  affected.  Diarrhoea  is 
not  usually  a  marked  symptom  unless  tubercular  ulceration  has  taken  place. 
The  subsequent  course  of  these  cases  differs  much  ;  in  the  minority,  after 
several  months  of  hectic,  improvement  slowly  sets  in  and  the  patient  improves, 
for  a  time  at  least  appearing  fairly  well.  In  the  majority  the  fever  continues, 
the  wasting  becomes  more  apparent,  diarrhoea,  and  perhaps  cough,  come  on, 
and  the  child  sinks.  In  others,  the  lungs  remain  free  to  the  end,  but  mesen- 
teric disease  ensues,  ulceration  of  the  bowels  takes  place,  perhaps  local 
abdominal  abscesses  form,  and  the  liver,  spleen,  and  kidneys  become 
lardaceous.  In  only  four  of  the  thirty-eight  cases  of  fatal  tubercular 
peritonitis  mentioned  were  the  lungs  and  mediastinal  glands  found  entirely 
free  from  tubercle. 

Prog7iosis. — The  course  of  chronic  tubercular  peritonitis  is  usually  long, 
unless  some  intercurrent  disease,  as  tubercular  meningitis,  supervenes. 
Children  may  be  under  observation  for  many  months,  with  either  ascites  or 
induration  of  the  omentum,  with  more  or  less  hectic,  and  with  no  evidence 
of  any  active  disease  of  the  lungs,  and  finally  to  all  appearance  completely 
recover.  On  the  other  hand,  the  onset  of  diarrhoea,  hectic,  progressive 
emaciation,  and  cough,  with  evidence  of  lung  mischief,  points  to  the  exist- 
ance  of  more  or  less  generalised  tuberculosis,  which  necessarily  shortens 
the  duration  of  the  illness.  Albuminuria,  as  pointing  to  lardaceous  disease, 
would  be  of  bad  omen. 

Diagnosis. — When  a  child  is  brought  with  an  ascites  which  has  made 
its  appearance  gradually  without  pain  or  fever,  it  is  perhaps  not  unnatural  to 
attribute  the  collections  of  fluid  in  the  abdomen  to  obstructed  portal  circu- 
lation. In  an  adult  the  commonest  cause  of  ascites  is  cirrhosis  of  the  liver 
in  a  child  by  far  the  most  frequent  cause  is  chronic  tubercular  peritonitis. 
In  a  given  case  it  is  perhaps  quite  impossible  to  make  a  certain  diagnosis,  inas- 
much as  for  a  while  the  ascites  may  be  the  only  symptom  present ;  there  may 
be  a  complete  absence  of  pain  or  tenderness,  and  the  most  careful  palpation 
fail  to  detect  any  induration  of  the  omentum.  The  bowels  may  float  up  and 
cause  a  resonant  note  on  percussion  at  the  umbilicus  when  the  patient  is  on 
his  back,  the  resonance  shifting  to  the  flank  which  is  uppermost  when  he  lies 
on  his  side.  It  may  be  impossible  to  feel  the  edge  of  the  liver,  or  map  it  out 
by  percussion.  In  other  cases,  however,  there  will  be  less  difficulty,  for  there 
is  hectic  fever,  or  diarrhoea,  or  abdominal  pain  and  tenderness,  or  after  para- 
centesis lumps  or  masses  of  induration  may  be  felt.  A  family  history  of 
tuberculosis  would  naturally  favour  the  view  of  tubercular  peritonitis  ;  and 
occasionally  the  presence  of  a  cheesy  deposit  in  a  testis  will  decide  the 
diagnosis.     The  fact  that  the  fluid  is  encysted  is  in  favour  of  tuberculosis. 

Morbid  Analoiny. — Fluid  varying  in  quantity  will  be  found  in  a  few 
cases  ;  it  may  be  clear  or  cloudy  serum  or  pus,  in  which  latter  case  it  is 


Tubercular  Peritonitis  1 3  r 

usually  localised  :  it  is  not  uncommon,  on  separating  the  intestines,  to  find 
small  local  collections  of  pus.  Tubercles  and  lymph  are  usually  present  on 
the  great  omentum  and  mesentery,  matting  the  intestines  together,  also 
between  the  Hver  and  diaphragm  and  around  the  spleen  ;  where  there  is  no 
large  collection  of  fluid,  the  adhesions  are  freciuently  very  extensive  ;  the  in- 
testines and  stomach  may  be  adherent  to  the  abdominal  wall,  so  that  on 
opening  the  abdomen  the  intestines  are  cut  into.  The  intestines,  mesentery, 
great  omentum,  liver,  and  spleen  may  be  so  matted  together,  partly  by  lymph, 
partly  by  fibroid  adhesions,  that  it  may  be  impossible  to  separate  them. 
The  intestines  may  be  so  adherent  and  bound  down  as  to  form  bends  and 
kinks  that  it  is  impossible  to  unravel.  Cheesy  mesenteric  glands  and  tuber- 
cular ulcers  will  very  likely  be  present. 

Treatment.— Pvay  pain  and  tenderness  in  the  abdomen  in  a  child  with 
tubercular  tendencies  should  excite  apprehension  and  never  be  neglected. 
Rest  in  bed  must  be  enjoined,  and  a  diet  consisting  of  beef  tea  and  milk 
should  be  given.  The  pain  may  be  relieved  by  applications  of  belladonna 
and  glycerine  covered  with  cotton  wool,  or  by  fomentations.  The  bowels 
ought  to  be  relieved  by  enemata  and  la.xatives  rather  than  purgatives.  In 
the  chronic  stages,  when  the  abdomen  contains  fluid  or  there  is  evidence  of 
thickened  and  indurated  omentum  or  cheesy  masses,  mercurial  applications 
are  of  service.  An  ointment  of  yellow  o.^ide  of  mercury  (20  grains  to  the 
oz.),  with  an  equal  quantity  of  ung.  belladonna?,  may  be  applied,  with  cotton 
wool  to  cover  it.  Lin.  hydrarg.  may  be  used,  but  salivation  is  likely  to 
follow  if  continued  for  too  long  a  time.  Tonics  and  cod-liver  oil  emulsion 
should  be  given.  Chronic  purulent  peritonitis,  whether  tubercular  or  not, 
should  be  treated  by  incision  and  drainage,  if  the  child's  health  is  failing  ; 
and  there  is  good  evidence  to  show  that  not  only  may  temporary  relief  be 
thus  given,  but  long  lasting,  if  not  permanent,  recovery  may  take  place  as 
the  result  of  incision.  Even  where  the  fluid  is  not  purulent  in  obstinate 
cases  drainage  is  of  service  ;  it  appears  to  cause  adhesions  and  thus  to 
prevent  the  re-collection  of  fluid,  while  at  the  same  time  cicatrisation  takes 
place.  We  have  little  doubt  that,  in  all  cases  of  tubercular  peritonitis 
in  which  there  is  any  considerable  collection  of  fluid,  whether  purulent  or 
not,  the  abdomen  should  be  opened  and  drained  as  soon  as  it  is  evident  that 
in  spite  of  treatment  extending  over  some  months  no  improvement  is  taking 
place.  We  have  successfully  employed  this  method,  and  are  impressed  with 
its  value. 

.acute  Obstruction  of  the  Bowels. — Children  occasionally  suffer  from 
acute  obstruction  caused  by  twists  in  the  bowel,  constricting  bands,  impac- 
tion of  foreign  bodies,  and  internal  hernia  ;  by  far  the  most  frequent  cause 
is,  however,  an  intussusception. 

Intussusception 

The  commonest  cause  of  obstruction  in  infants  is  the  presence  of  an 
invagination  of  the  bowel.  Many  reasons  have  been  given  for  this  somewhat 
frequent  accident.  There  is  no  doubt  that  one  cause  is  to  be  found  in  the 
great  reflex  irritability  of  the  muscular  coat  of  the  infant's  bowel  ;  vigorous 
peristalsis  is  easily  set  up,  and  moreover,  the  intestinal  walls  being  thinner 
during  infancy  than  in  later  life,  an  invagination  of  one  portion  of  the  gut 

K  2 


132  Diseases  of  the  Digestive  System 

into  a  lower  portion  more  readily  takes  place.  This  is  seen  in  the  post-inortevi 
invaginations  so  often  found  :  the  act  of  dying  seems  to  stimulate  the 
peristalsis  of  the  bowels,  and  it  is  no  uncommon  thing  to  find  on  \}i\t  post- 
mortem table  many  invaginations  in  the  ileum  an  inch  or  two  in  length.  In 
some  cases  an  accident,  such  as  falling  out  of  bed,  or  some  rapid  movement 
up  and  down  in  the  parent's  or  nurse's  arms,  has  preceded  symptoms  of  an 
intussusception,  and  it  is  possible  that  a  sudden  movement  might  cause  a 
toneless  piece  of  gut  to  become  invaginated.  It  must  also  not  be  forgotten 
that  the  infant's  intestines,  especially  the  cascum  and  colon,  are  more 
movable  than  those  of  an  adult,  having  a  wider  mesentery,  and  consec[uently 
one  piece  of  bowel  is  more  easily  dragged  into  another  portion. 

The  exciting  cause  of  intussusception  is  occasionally  found  to  be  a 
polypus,  more  often  an  inflammatory  thickening  of  the  caecum,  or  some 
hardened  nodule  of  faecal  matter  which  adheres  to  the  wall  of  the  gut,  and 

sets  up  local  peristalsis.  We  have  met 
with  a  case,  related  below,  in  which 
a  local  tubercular  peritonitis  causing 
thickening  of  the  bowel  was  the  im- 
mediate cause  of  the  invagination. 
Sometimes  tubercular  caseatmg  glands 
are  found  in  the  mesentery,  which  has 
been  dragged  into  an  intussusception. 
This  occurs  in  children  of  over  eighteen 
months  or  two  years  of  age,  rather  than 
in  infants.  It  is  quite  probable  that 
such  a  gland  pressing  into  the  wall  of 
the  gut  may  be  the  starting-point  of 
the  invagination. 

Fig.  ig. — Ileo-caecal  intussusception,   a,  Ileum  iiT-it.  „      j     *-„     4.i,„     r  c 

(the  intussusceptum);^,  cut  edge  of  window         With    regard   to   the    frequency    of 

in  colon   made  to  show_  the   middle   layer  ;     intUSSUSCeptionS  at  different  ageS,  it  has 
c,  colon  (the  Intussuscipiens).  ,  1  1       -iri     ,i      .  ,      r 

been  stated  by  r\\z  that,  out  of  293  cases, 
153  were  in  their  first  year,  and  of  these  98  were  from  four  to  six  months  of 
age.  According  to  Leichenstern,  out  of  122  cases,  T}>  were  under  a  year  old 
and  49  from  one  to  five  years  of  age.  It  is  certainly  the  common  experience 
that  the  majority  of  cases  occur  in  infants  under-a  year,  and  that  from  four 
to  six  months  of  age  is  a  very  common  time. 

In  at  least  three-fourths  of  the  cases  in  infants  the  invagination  is  ileo- 
ca;cal,  in  the  minority  of  cases  it  is  ileum  into  ileum  or  colon  into  colon.  In 
the  ileo-c£ecal  variety  the  ileum  enters  the  caecum,  not  through  the  ileo-ceecal 
valve,  but  the  csecal  valves  are  pushed  before  it,  so  that  the  valves  themselves 
occupy  the  lowest  part,  and  as  it  travels  downwards,  more  and  more  of  the 
ileum  enters,  dragging  its  mesentery  along  with  it  and  forming  the  inner  tube 
while  the  middle  layer  is  formed  by  the  inverted  ctecum  and  colon,  the 
colon  also  forming  the  outer  layer.  The  layers  of  an  intussusception  there- 
fore consist  of  (i)  an  outer  layer  of  intestine  into  which  the  invagination 
takes  place,  the  peritoneal  coat  being  external  and  the  mucous  membrane 
internal  ;  (2)  a  middle  layer  continuous  with  the  outer  layer  at  its  upper  end 
but  turned  inside  out  so  that  the  mucous  membrane  is  external  and  the 
peritoneum  internal  ;  (3)  an  internal  layer  formed  by  the  intestine  entering 


Intussusception  1 33 

the  outer  layer  with  its  mesentery  and  vessels,  and  this  becoming  nipped 
as  it  travels  downwards  forms  the  obstruction.  In  consequence  of  the 
mesentery  becoming  dragged  in,  the  included  intestine  does  not  lie  in 
the  centre  of  the  containing  gut,  but  is  more  or  less  tilted  to  one  side. 
As  a  result  of  the  invagination,  the  inner  and  middle  layers  become 
congested  and  oedematous  and  of  a  dark-red  colour  ;  blood  is  extra vasated 
from  the  congested  mucous  membrane  and  is  passed  per  rectum.  In  some 
cases,  lymph  is  thrown  out  by  the  serous  surfaces  and  a  local  or  general 
peritonitis  takes  place.  In  a  few  cases,  more  particularly  in  the  ileum  into 
ileum  variety,  sloughing"  may  take  place  and  the  invaginated  bowel  be 
separated  and  passed  per  rectum,  while  f^ces  may  be  extravasated  or 
recovery  take  place  by  a  process  of  cicatrisation.  The  extent  to  which  life 
is  threatened  depends  very  largely  upon  the  tightness  with  which  the  bowel 
is  nipped  and  the  circulation  of  blood  obstructed,  and  this  appears  to  vary 
to  a  considerable  extent,  so  that  death  may  ensue  in  a  few  hours  with  the 
symptoms  of  collapse,  or,  especially  in  older  children,  where  the  bowel 
is  only  partially  obstructed  and  the  circulation  of  blood  through  it  but 
slightly  interfered  with,  the  course  may  be  chronic,  going  on  for  weeks  or 
even  months. 

Symptoms.- — An  infant  of  a  few  months  who  may  very  probably  have 
suffered  for  a  few  days  from  symptoms  of  bowel  irritation,  suddenly  begins 
to  kick  and  scream  as  if  in  violent  pain  which  nothing  appears  to  relieve.  It 
soon  begins  to  vomit  continuously,  and  strain  as  if  it  wanted  to  pass  a  stool, 
but  nothing  escapes  but  a  little  blood  and  mucus.  In  the  intervals  between 
the  attacks  of  vomiting  and  colic,  the  infant  may  be  tolerably  quiet,  but  it  is 
usually  restless  and  moaning  as  if  in  pain.  On  examination  of  the  abdomen 
with  the  warm  hand  it  is  usually  found  more  or  less  soft  and  flaccid,  and  on 
careful  palpation  in  the  course  of  the  transverse  colon,  an  inch  or  so  above 
the  umbilicus  and  towards  the  left  hypochondriac  region,  an  elongated 
tumour  may  be  felt,  which  is  movable,  and,  as  a  rule,  not  acutely  tender. 
There  may  be  also  a  feeling  of  want  of  resistance  in  the  right  lumbar 
i"egion  from  the  absence  of  the  caecum  and  ascending-  colon.  In  very 
fat  infants  it  may  be  impossible  to  detect  such  a  tumour.  We  must  not 
however,  forget  that  if  an  early  examination  be  made  no  tumour  may  be  felt, 
inasmuch  as  the  invaginated  portion  of  ileum  may  only  have  passed  two  or 
three  inches  into  the  caecum  and  lie  too  deeply  to  be  felt.  If  it  travels  as  far 
as  the  splenic  flexure  of  the  colon,  it  is  tolerably  certain  to  be  felt.  In  some 
cases,  as  in  one  related  below,  no  tumour  was  felt  after  forty-eight  hours. 
The  rectum  should  be  next  carefully  explored  with  the  finger,  and  the  presence 
of  a  tumour  there,  which  is  pressed  down  when  the  child  strains,  while  the 
withdrawn  finger  is  covered  with  blood,  would  establish  the  diagnosis.  The 
position  of  the  tumour  necessarily  varies  according  to  the  length  of  the 
included  gut  ;  but  inasmuch  as  the  colon  is  nearest  the  abdominal  wall 
where  it  crosses  the  upper  part  of  the  umbilical  region,  if  this  part  is  involved, 
as  it  usually  is,  the  tumour  will  be  most  readily  felt  here.  The  temperature 
is  mostly  normal  or  subnormal,  unless  there  is  peritonitis,  when  it  may  be 
raised  a  degree  or  two.  The  tumour  is  usually  not  acutely  tender,  but  if 
the  case  be  an  acute  one,  or,  in  other  words,  if  the  included  gut  be  tightly 
jammed  and  its  vessels  strangulated,  the  child  may  scream  on   its   being 


134  Diseases  of  the  Digestive  System 

pressed.  If  the  case  continues  unrelieved,  the  vomiting,  straining,  and 
distress  continue,  the  child  wears  an  anxious,  pinched  expression,  with 
sunken  eyes,  and  dies  with  the  symptoms  of  collapse.  The  period  at  which 
death  takes  place  varies  ;  in  infants  it  may  be  within  twenty-four  hours, 
more  often  from  the  third  to  the  fifth  day. 

While  the  above  description  applies  to  the  majority  of  cases,  it  must  be 
borne  in  mind  that  the  symptoms  are  at  times  far  less  well  marked,  so  that 
the  presence  of  an  intussusception  may  be  overlooked  ;  there  may  be  perhaps 
vomiting,  colicky  pains,  and  mucoid  stools,  the  infant  dying  in  convulsions.  On 
the  other  hand,  it  is  possible  that  an  invagination  may  occur,  and  fortunately 
right  itself  before  it  becomes  tightly  impacted. 

We  have  already  remarked  that  an  intussusception  is  by  far  more  common 
in  infants  under  six  months  or  a  year  than  it  is  in  older  children,  and  when  it 
occurs  in  the  latter,  the  symptoms  in  the  early  stages  especially  may  be  ill 
defined  and  consequently  the  diagnosis  is  difficult.  There  will  be  vomiting 
and  severe  colic  with  constipation,  and  in  many  cases  no  tumour  can  be  felt, 
and  there  may  be  an  entire  absence  of  mucus  or  blood  per  rectum.  In  other 
cases  the  course  is  more  subacute  or  chronic,  there  being  no  actual  strangula- 
tion of  bowel,  at  first  at  least,  and  the  obstruction  to  the  passage  of  fteces  not 
being  complete.  In  some  of  these  cases  there  is  some  tubercular  lesion, 
either  old  or  recent,  present  in  the  abdomen,  which  has  in  some  way  or  other 
contributed  to  the  commencement  of  the  invagination.  (See  Chronic 
Obstruction  of  Bowels.) 

The  ileum  into  ileum  variety  is  very  uncommon  in  our  experience  in 
children.  The  symptoms  produced  will  resemble  those  of  a  strangulated 
hernia  with  feecal  vomiting  and  severe  colic,  and  there  may  be,  but  not  neces- 
sarily, mucus  and  blood  passed  by  stool. 

The  following  case  illustrates  some  of  the  difficulties  of  diagnosis,  inasmuch 
as  no  blood  or  mucus  was  passed  by  the  bowel  and  no  tumour  could  be  felt. 

hitussusceptioti,  Gangi'e?7e ,  Peritonitis. — A  girl  of  2  years  (seen  with  Dr.  A.  Hopkinson) 
was  knocked  over  b}'  a  perambulator,  falling  somewhat  heavily  on  her  side.  Four  days 
afterwards,  during  which  period  her  bowels  had  acted  normally,  she  was  seized  with  acute 
vomiting  and  colic.  She  cried  out  from  time  to  time,  placing  her  hand  on  her  abdomen, 
saying,  '  Pain,  mother,  pain.'  An  enema  was  given  without  result.  On  the  second  day  of 
the  illness  the  vomiting  and  pain  continued,  the  temperature  was  99'6,  the  tongue  was 
clean,  the  abdomen  was  not  distended  or  tender.  On  the  third  day  some  chloroform  was 
given,  and  a  careful  examination  made  of  the  abdomen,  but  no  tumour  could  be  detected. 
Fourth  day.  The  abdomen  was  distended  and  tympanitic  with  some  dulness  in  the  left 
groin  ;  the  pulse  rapid  and  feeble,  the  eyes  sunken,  the  vomiting,  especially  after  food  or 
fluid,  continued,  and  also  the  paroxysms  of  pain.  Death  occurred  on  the  fifth  day.  No 
stools  or  flatus  were  passed  during  the  illness,  no  blood  or  mucus,  and  no  tumour  was  felt. 
Post-mortem.  Early  stage  of  a  general  peritonitis,  most  marked  on  the  right  side.  The 
large  bowel  was  empty  except  the  cascum,  the  latter  forming  a  tumour  nearly  three  inches 
in  length,  the  ileum  having  become  impacted  into  it  for  about  that  distance.  No  amotmt 
offeree  sufficed  to  reduce  it.  On  incision  of  the  caecum,  the  included  ileum  was  found  to 
be  gangrenous.  The  appendix  was  long  but  otherwise  normal.  The  mesentery  contained 
some  tubercular  glands.  (We  are  much  indebted  to  Dr.  A.  Hopkinson  for  his  notes  of 
the  case. ) 

The  diagnosis  in  this  case  was  exceedingly  difficult.  The  girl  had  eaten 
some  indigestible  food  a  day  or  two  before,  more  or   less    of  which   had 


In  tussHsceptzon 


135 


returned  in  her  vomit,  and  it  was  at  first  naturally  assumed  that  the  improper 
food  was  the  cause  of  the  sickness  and  coHc.  Apparently  the  lower  two  or 
three  inches  of  the  ileum  passed  through  the  ileo-cascal  valves  and  quickly 
became  tightly  jammed. 

In  the  following'  case  there  was  an  old  tubercular  peritonitis  and  caseous 
mesenteric  glands  ;  the  latter  were  found  dragged  into  the  invagination. 

hitiissusceplion  :  Partial  Obstnictioii. — Kathleen  P.,  aged  5  years,  was  admitted  into 
the  Children's  Hospital,  September  27,  1895.    The  girl  had  enjoyed  good  health  up  to  three 


Fig.  20. — Iiitussusceptum 
removed  by  operation. 
The  invagination  was 
ileo-caecal.  (From  a 
drawing  by  Dr.  W.  E. 
Fothergill.) 


Fig.  21. — Longitudinal  section  of  inLiissusceptum, 
fig.  20.  The  dotted  lines  show  continuation  of 
layers  of  intestine  ;  the  inner  being  small  intes- 
tine, the  outer  the  encasing  colon  ;  in  jii  m,  mu- 
cous membrane  of  intestine  ;  s  s  s,  peritoneal 
coat  ;  g,  caseous  mesenteric  gland  dragged  in. 
(From  a  drawing  by  Dr.  W.  E.  Fothergill.) 


months  before  admission,  but  latterly  had  been  getting  thinner,  and  at  times  suffered  from 
abdominal  pains  and  vomiting.  It  was,  however,  only  during  the  lasfthree  weeks  that 
she  had  been  attended  by  a  doctor,  the  abdominal  pain  being  very  severe,  the  vomiting 
persisting  and  the  stools  being  sometimes  simply  loose,  at  other  times  consisting  of  pure 
blood  or  blood  and  mucus.  The  vomit  was  never  fsecal,  but  was  sour-smelling  and 
greenish  in  colour.  The  attacks  of  abdominal  pain  had  been  exceedingly  severe,  so  that 
she  rolled  about  in  bed  in  agony.  When  admitted  she  was  in  a  semi-collapsed  state,  but  in 
much  pain,  twisting  and  writhing  about  in  bed.  The  abdomen  was  somewhat  distended  : 
the  coils  of  the  intestines  could  be  distinctly  seen  through  the  abdominal  walls.  The  ab- 
domen was  slightly  tender  to  the  touch,  and  an  elongated  tumour  could  be  felt  in  the  left 


136  Diseases  of  the  Digestive  System 

iliac  fossa.  This  tumour  was  movable  and  could  be  rolled  about  under  the  fingers,  and 
could  be  traced  upwards  to  the  edge  of  the  ribs,  where  it  was  gradually  lost.  The  finger  in 
the  rectum  detected  a  soft  cylindrical  mass,  high  up  with  a  definite  '  os,'  into  which  the  finger 
could  be  introduced.  There  was  blood  and  mucus  present  in  the  rectum.  It  was  abun- 
dantly clear  that  the  only  treatment  was  to  open  the  abdomen,  and  if  possible  reduce  the 
invagination.  Accordingly  the  abdomen  was  opened  in  the  left  linea  semilunaris,  and  the 
intussusception  readily  exposed.  It  was  quite  irreducible,  so  a  longitudinal  incision  was 
made  in  the  intussuscipiens  and  the  intussusceptum  excised  ;  the  ends  were  united  by  an 
Allingham's  bone  bobbin  and  Lembert's  sutures,  but  the  child  died  in  a  few  hours.  It 
would  have  been  better  in  this  case  to  have  strictly  followed  Barker's  method,  since  alter 
excision  of  the  inner  portion  the  ends  separated  and  some  fascal  contamination  occurred. 
(See  figs.  20  and  21.) 

Morbid  Anatomy. — On  making  a  post-nio'tem  examination,  care  must 
be  taken  to  distinguish  between  an  intussusception  which  has  taken  place 
during  hfe  and  given  rise  to  the  symptoms  noted,  andan  intussusception 
which  is  post  mortem  and  caused  by  the  irregular  yet  vigorous  peristalsis 
of  the  bowels  which  may  take  place  during  the  act  of  dying  or  after  death. 
In  the  latter  case  the  invagination  involves  the  ileum,  or  at  any  rate  the 
small  gut,  and  there  are  often  several  of  them.  They  are  rarely  more  than 
an  inch  or  two  in  length,  are  readily  pulled  out  by  gentle  traction,  and  while 
a  ring  of  congestion  may  be  seen  near  the  seat  of  constriction,  or  where  the 
gut  has  been  doubled  on  itself,  there  is  no  oedema  or  marked  congestion  or 
effused  lymph.  A  post-mortem  invagination  does  not  completely  occlude 
the  passage  of  the  gut.  In  the  examination  in  a  case  of  the  ileo-caecal 
variety  which  has  become  strangulated,  an  elongated  mass,  dark  red  in 
colour,  is  seen  lying  in  the  course  of  the  transverse  colon  continuous  with  it 
at  its  lower  end,  while  the  ileum  with  its  mesentery  is  seen  to  enter  at  its 
upper  end  ;  the  ascending  colon  and  ceecum  will  have  disappeared.  In 
most  cases  the  contained  gut  cannot  be  withdrawn  without  tearing,  as  it  has 
become  rotten  from  gangrene.  Its  passage  will,  in  an  acute  case,  be  com- 
pletely occluded,  partly  on  account  of  the  cedematous  and  congested  two 
inner  layers,  partly  by  reason  of  the  tilting  on  one  side  of  the  inner  gut 
through  the  dragging  in  of  its  mesentery.  Lymph  may  be  found  effused 
between  the  two  peritoneal  surfaces,  gluing  them  together,  and  there  may  be 
evidence  of  a  more  general  peritonitis. 

In  chronic  cases  less  congestion  is  seen,  the  bowel  probably  is  not  entirely 
obstructed,  and  the  bowel  above  is  generally  hypertrophied  and  its  mucous 
membrane  in  a  condition  of  ulceration.  We  have  already  noted  that  some- 
times chronic  inflammatory  thickening  is  found  in  the  caecum,  and  tubercular 
lesions  of  the  peritoneum  and  glands. 

Diag7iosis. — The  diagnosis  in  an  acute  case  in  an  infant  is  not  likely  to 
give  rise  to  difficulty,  inasmuch  as  the  sudden  attack  of  vomiting,  with  pain, 
straining,  and  the  passage  of  blood  and  mucus  from  the  bowel,  and  the  dis- 
covery of  an  elongated  tumour  through  the  abdominal  wall  or  per  rectum, 
make  the  case  tolerably  clear.  We  may  be  more  in  doubt  if  with  the  above 
symptoms  no  tumour  can  be  felt  ;  but  we  must  bear  in  mind  that  a  short 
ileo-caecal  invagination  may  be  present  and  lie  too  deeply  in  the  right  lumbar 
region  to  be  felt.  But  the  question  of  the  presence  of  an  intussusception 
sometimes  arises  in  infants  who  are  suffering  from  symptoms  of  obstruction 
to  the  bowels  of  an  uncertain  origin,   possibly  with    a  certain  amount  of 


Intussusception  137 

thickening  or  resistance  in  the  right  ihac  fossa,  which  may  be  ckic  to  the 
impaction  of  feces  in  the  ctecum  or  to  an  invagination.  In  all  such  cases,  as 
long  as  any  doubt  exists  purgatives  should  be  avoided,  and  small  doses  of 
opium  given  to  allay  the  pain  and  straining.  Purgatives  have  been  shown 
by  D'Arcy  Power  to  have  a  peculiarly  fatal  effect  in  intussusception  even 
when  operation  has  been  subsequently  resorted  to.  If  there  is  pain  on  deep 
pressure,  it  is  better  to  avoid  enemata,  trusting  rather  to  narcotics.  In  older 
children  the  errormay  be  made  of  mistaking  an  ileo-colitisfor  an  invagination 
of  the  bowel  and  vice  versa  (see  ILEO-COLITIS),  or  obstruction  of  the  bowels 
from  other  causes  may  be  taken  for  intussusception.  Complex  forms  of 
invagination  are  sometimes  found  ;  thus  Golding  Bird  has  recorded  a  case  in 
which  an  ordinary  intussusception  downwards  was  enveloped  in  a  second 
retrograde  invagination,  and  another  in  which  an  upward  invagination  took 
place  into  a  persistent  Meckel's  diverticulum.  Appendicular  intussusception  is 
alluded  to  later. 

Treatment. — The  treatment  which  is  to  be  adopted  must  necessarily 
vary  according  to  the  acuteness  of  the  case  and  the  time  the  symptoms  have 
lasted,  for  if  the  bowel  has  passed  into  a  gangrenous  condition  it  is  obvious 
that  only  harm  can  be  done  by  treatment  which  might  have  been  of  the 
greatest  service  in  an  earlier  stage.  The  questions  to  ask  oneself  before  com- 
mencing treatment  are,  what  is  the  state  of  the  invagination  ?  is  the  gut 
tightly  jammed  ?  is  it  gangrenous  ?  Unfortunately  these  questions  are  very 
difficult  to  answer,  inasmuch  as  in  some  cases  the  inner  layer  of  bowel 
becomes  tightly  impacted  from  the  first,  and  no  amount  of  force  applied 
by  distending  the  bowel  per  rectum  will  replace  it,  while  in  other  cases  suc- 
cess has  attended  inflation  of  the  lower  bowel  with  air  several  days  or  even 
a  week  after  the  onset  of  symptoms.  Thus  in  a  child  ^  aged  7  months,  under 
the  care  of  Dr.  J.  S.  Bury,  injections  of  oil  and  afterwards  of  air  were  employed 
fourteen  hours  from  the  commencement,  but  failed  to  reduce  the  invagina- 
tion, the  infant  dying  twelve  hours  later,  within  twenty-six  hours  of  the  onset  ; 
at  the  post-mortem  '  reduction  was  quite  impossible  without  tearing  the  gut  ; ' 
there  was  some  lymph  effused  locally.  In  this  case,  by  the  end  of  twenty- 
four  hours,  the  bowel  was  tightly  strangulated,  and  neither  by  injections  nor 
abdominal  section  could  reduction  have  been  effected.  Such  a  case  is  no 
doubt  exceptional,  and  it  would  probably  have  ended  fatally  under  any  cir- 
cumstances unless  mechanical  replacement  could  have  been  undertaken,  or 
laparotomy  performed  within  a  very  short  time  of  the  seizure.  By  the  time 
the  invaginated  portion  of  the  bowel  has  travelled  along  the  colon  as  far  as  the 
rectum,  the  collapse  produced,  especially  in  a  small  infant,  is  very  great,  and  . 
the  difficulties  in  the  way  of  replacement  are  necessarily  much  greater  than 
if  only  a  few  inches  of  bowel  are  involved.  But  cases  appear  to  differ  very 
much  in  the  amount  of  oedema  and  congestion  taking"  place  in  the  nipped 
bowel,  and  consequently  in  the  difficulty  of  replacement.  While  some  cases, 
such  as  the  one  just  referred  to,  are  acute  and  irreducible  almost  from  the 
first,  others  are  reported  in  which  the  intussusception  was  reducible  some  days 
after  the  onset  of  symptoms  ;  in  one  case,  reported  by  Dr.  W.  B.  Cheadle,- 
in  a  boy  aged  5|-  years,  the  invagination  was  successfully  reduced  by  massage 
and  the  injection  of  air  on  the  seventh  day  from  the  onset.     In  another  case, 

^  Medical  Times,  Feb.  19,  1881.  2  Lancet,  Oct.  23,  1886. 


138  Diseases  of  the  Digestive  System 

reported  by  F.  H.  Elliott,^  in  an  infant  of  8  months,  attempts  at  intervals  to 
reduce  the  invagination  were  at  first  only  partially  successful,  but  finally 
succeeded. 

As  soon,  then,  as  the  existence  of  acute  intussusception  has  been  ascer- 
tained, it  becomes  necessary  to  decide  what  method  of  treatment  should  be 
adopted. 

Recoveries  after  spontaneous  reduction  and  after  sloughing  have  been 
recorded,  but  they  are  so  rare  that  waiting  for  a  natural  cure  means  practically 
abandoning  the  child  to  almost  certain  death.  Even  if  recovery  by  sloughing 
takes  place,  the  risk  of  subsequent  stricture  has  to  be  considered.  It  is  then 
clear  that  some  attempt  at  reduction  should  be  made,  and  we  have  the  fol- 
lowing plans  at  our  disposal  for  this  purpose,  (i)  Inversion  of  the  child, 
combined  with  external  taxis  or  succussion.  The  child  is  held  up  by  the  legs 
with  the  head  downwards,  and  an  attempt  made  to  draw  the  contents  of  the 
abdomen  to  the  upper  part  of  the  abdominal  cavity  by  kneading  and  stroking 
with  the  hands  through  the  abdominal  wall,  or  by  sudden  shaking  movements 
of  the  child  an  attempt  is  made  to  dislodge  the  intussusception.  It  is  clear 
that  this  plan  can  only  be  expected  to  succeed  when  the  intussusception  is 
small  in  extent  and  recent  in  formation  ;  it  is  in  such  cases  worth  a  trial, 
since  it  is  unattended  with  danger.  Chloroform  should  be  given  during  the 
manipulations. 

(2)  Distension  of  the  bowel  with  fluid  or  air  in  the  hope  of  pushing  back 
the  invagination.-  If  fluid  injections  are  employed  an  enema  tube  fitted  with 
an  anal  shield  should  be  passed  into  the  rectum,  and  warm  water  or  oil 
allowed  to  flow  into  the  bowel  from  a  vessel  raised  above  the  level  of  the 
patient's  body.  The  amount  thus  injected  must  vary  with  the  age  of  the 
child  and  the  position  of  the  intussusception  ;  from  one  to  two  pints  is  about 
the  usual  quantity,  and  a  fall  of  not  more  than  three  feet  is  required. 

Inflation  by  air  is  best  managed  by  passing  the  nozzle  of  an  ordinary 
pair  of  bellows,  fitted  with  the  pipe,  into  the  rectum,  and  blowing  air  in  till 
the  tumour  is  felt  to  give  way,  or  it  is  not  safe  to  distend  any  further.  In 
both  these  methods  the  abdomen  should  be  carefully  watched,  and  a  hand 
kept  on  the  intussusception  tumour  to  feel  for  any  change  in  its  size  or  posi- 
tion. 

The  following  cases  illustrate  the  success  of  these  methods  of  treatment : 

Intussusception ;  Ifijection  of  Air ;  Recovery. — A  fine  healthy  infant,  6  months  old, 
was  siTddenly  seized,  on  the  evening  of  January  2  with  griping  pains  and  tenesmus.  It 
had  been  brought  up  on  the  breast,  with  a  bottle  or  two  a  day  of  cow's  milk.  The  mother 
was  menstruating  for  the  first  time,  and  the  infant  was  cutting  two  lower  teeth.  His 
mother  gave  him  an  enema  with  a  small  ball  syringe,  which  brought  away  a  large  curdy 
stool.  During  the  night  he  was  very  restless,  vomiting  frequently,  and  straining  con- 
stantly, and  at  7  A.M.  passed  a  bloody  stool  with  mucus  sufficient  to  saturate  an  ordinary 
napkin.  We  saw  him,  with  Dr.  E.  H.  Smith,  of  Knutsford,  next  morning,  January  3, 
fifteen  hours  after  the  seizure.  His  face  was  placid,  not  drawn  or  distressed  ;  there  was 
no  fever ;  the  abdomen  was  flaccid  and  not  distended,  and  could  be  easily  palpated  in 
every  part.     On  deep  pressure  an  elongated  tumour  was  felt ;  the  left  end  was  most  dis- 


1  Lancet,  Jan.  8,  1887. 

2  Vide  Mortimer,  Lancet,  May  23,  1891,  p.  1144,  for  an  account  of  experiments  upon 
distension. 


Intussusception  139 

tinct,  and  was  situated  in  the  left  lumbar  region,  just  below  the  ribs  and  near  the  tip  of  the 
spleen  ;  it  could  be  traced  from  left  to  right  across  the  abdomen  for  two  or  three  inches, 
its  outline  being  gradually  lost.  It  was  movable  and  not  tender.  No  tumour  could  be 
felt  in  the  right  lumbar  region  or  per  rectum,  but  the  finger,  on  being  withdrawn,  was 
covered  with  blood.  We  at  once  decided  to  reduce  the  invagination,  which  we  believed 
to  exist,  by  distending  the  colon  by  water  pressure.  The  attempt  proved  a  failure,  as  the 
water  returned  by  the  side  of  the  catheter  into  the  rectum  without  distending  the  colon  to 
any  great  e.xtent.  We  ne.xt  tried  the  inflation  of  air,  by  means  of  an  ordinary  Higginson's 
syringe,  the  bone  nozzle  being  inserted  into  the  rectum  ;  the  pelvis  was  raised,  and  the 
tumour  gently  kneaded,  while  air  was  forced  into  the  bowel  by  squeezing  the  ball  of  the 
syringe.  After  four  or  five  squeezes  the  tension  in  the  colon  was  felt  to  be  considerable, 
then  followed  a  gurgling  noise,  and  the  tumour  disappeared.  We  continued  to  pump 
more  air  in,  in  the  hope  that  we  might  effect  the  complete  reduction  of  the  invagination. 
The  infant  seemed  relieved,  and  went  to  sleep  for  some  hours  ;  but  towards  evening  the 
straining  retiu-ned,  and  he  spent  a  restless  night.  There  was  no  vomiting  ;  he  passed  per 
rectum  some  flatus,  blood-stained  mucus,  and  a  little  curd.  We  saw  him  again  next  day, 
January  4.  There  was  some  distress  noticeable  now  on  his  face  ;  he  had  colicky  pains  at 
times  ;  there  was  no  tumour  to  be  felt.  A  minim  of  tr.  opii  was  given,  and  the  infant 
was  placed  in  a  warm  bath  for  ten  minutes.  The  colon  was  slowly  distended  with  warm 
water  by  means  of  a  Higginson's  syringe,  the  infant  being  in  an  inverted  position  ;  no 
immediate  effect  appeared  to  be  produced.  Three  hours  later  another  minim  of  tr.  opii 
was  given.  .\n  hour  later,  after  another  warm  bath,  he  passed  a  copious  yeUow  liquid 
stool.  From  this  time  he  continued  to  improve,  though  for  a  few  days  he  was  griped  at 
times  and  passed  small  quantities  of  blood  and  mucus  in  his  stools.  Small  doses  of  opium 
were  given  for  a  few  days. 

Intussusception  ;  Injection  of  Water;  Recovery. — A  healthy  infant  of  5  months,  who 
was  nursed  at  the  breast  for  three  months,  and  latterly  fed  on  milk  and  water,  was  seized, 
in  the  evening  of  February  7,  with  vomiting  and  abdominal  pain.  He  had  been  constipated 
for  some  time  previously,  and,  for  a  day  or  two,  more  restless  than  usual.  During  the 
night  he  passed  some  blood  per  rectum.  He  continued  much  in  the  same  state  during 
February  8  and  9.  We  saw  him  with  Dr.  Massiah,  of  Didsbury,  on  the  evening  of  the  9th. 
There  was  no  distress  visible  on  his  face,  but  he  was  pale  and  weaker  than  usual.  •  The 
abdomen  was  semi-distended  and  flaccid  ;  no  tumour  could  be  felt,  though  we  were  able 
to  press  deeply  into  the  abdomen.  He  strained  at  times  ;  and  the  finger,  introduced  into 
the  rectum,  returned  covered  with  dark  decomposing  blood.  A  minim  of  tr.  opii  was 
gi\'en,  and  he  was  put  into  a  warm  bath  ;  chloroform  was  given,  and  warm  water  injected 
per  rectum  by_  means  of  a  Higginson's  syringe.  There  was  much  straining  and  resistance 
at  first,  but  this  was  gradually  overcome.  It  was  evident,  on  percussion,  that  the  water 
reached  the  ascending  colon  and  caecum.  Having  distended  the  bowel  three  times  with 
the  water,  we  resolved  to  wait  and  see  the  effect.  After  the  last  injection  he  vomited  some 
stercoraceous  fluid.  Four  hours  afterwards  he  passed  a  liquid  stool  and  made  a  good 
recovery. 

These  plans  are  open  to  the  objections,  first,  that  there  is  distinct  danger 
of  over-distension  and  rupture  of  the  bowel,  as  shown  by  the  experiments  of 
Bryant  and  others  ;  secondly,  that  they  can  only  succeed  where  no  adhesions 
have  formed  between  the  adjacent,  peritoneal  surfaces  ;  and  thirdly,  that 
even  if  reduction  does  apparently  take  place  it  may  be  incomplete  or  invagi- 
nation may  recur.     A  case  of  our  own  well  illustrates  this  last  fact. 

Intussusception  ;  Abdominal  Section;  Death. — Harold  T.,  aged  seven  months,  was 
admitted  into  the  Children's  Hospital,  May  30, 1887,  with  symptoms  of  acute  intussuscepdon 
of  three  days'  diuation.  The  invagination  could  be  felt  externally  in  the  left  iliac  region, 
and  internally  per  rectum.  Under  chloroform  inflation  was  employed  without  success  ; 
ten  ounces  of  water  were  then  injected  through  an  india-rubber  tube  three  feet  long,  with 
the  result  of  causing  disappearance  of  the  tumour  and  increase  of  resistance  pre\"iously 
deficient  in  the  right  iliac  area.    He  slept  quietly  for  some  hoiu-s,  and  then  began  to  scream 


140  Diseases  of  the  Digestive  System 

again,  and  the  intussusception  reappeared.  Injection  was  again  apparently  successful, 
and  the  child  spent  a  quiet  night.  The  next  afternoon  the  symptoms  reappeared,  but 
were  once  more  relieved  by  injection.  The  next  day  the  general  condition  was  worse,  and, 
as  it  was  clear  that  no  complete  reduction  had  taken  place,  abdominal  section  was  per- 
formed, the  intussusception  found  and  reduced  ;  the  bowel  was  inflamed  but  not  gan- 
grenous, there  were  no  adhesions,  and  the  invagination  was  ileo-csecal.  The  child  sank^ 
and  died  an  hour  later. 

(3)  Abdominal  section  may  be  performed  and  the  obstruction  relieved  by 
more  direct  means.  The  section  is  best  made  in  the  median  line  below  the 
umbilicus,  the  bladder  having  been  previously  emptied.  As  soon  as  the 
abdomen  is  opened,  the  intussusception  should  be  drawn  to  the  surface  and 
carefully  examined.  If  the  bowel  is  in  good  condition  a  careful  attempt 
should  be  made  by  gentle  traction  to  withdraw  the  '  intussusceptum.'  Re- 
duction is  sometimes  best  managed  by  squeezing  the  tumour  and  drawing 
the  '  intussuscipiens  '  off  the  '  intussusceptum,' rather  than  by  directly  pulling 
out  the  invaginated  gut.  If  this  can  be  done  and  the  bowel  is  not  too  much 
mjured  for  recovery,  it  should  be  left  to  itself  and  the  wound  closed. 

Intussiiscepiio7i ;  Abdominal  Section. — In  a  case  which  we  saw  with  Dr.  Cox,  of 
Eccles,  his  patient,  a  child  of  eight  weeks  old,  had  symptoms  of  twelve  hours'  duration. 
With  the  help  of  Drs.  J.  J.  and  F.  Cox  and  Hutton,  an  attempt  was  made  to  reduce  the 
invagination  by  injection  ;  this  partially  succeeded,  but  a  nodule  could  still  be  felt  in  the 
right  h3rpochondrium.  We  therefore  opened  the  abdomen  and  drew  up  this  nodule, 
which  consisted  of  the  caecum  with  the  small  intestine  entering  it.  At  this  point  there 
had  been  evidently  a  previous  local  inflammation,  since  the  parts  were  much  thickened 
and  indurated,  and  the  adjacent  glands  were  enlarged.  The  intussusception  had  been 
reduced,  and  nothing  more  appeared  necessary.  The  abdomen  was  closed,  and  the 
child  got  quite  well.  It,  however,  unfortunately  died  of  pneumonia  three  or  four  weeks 
later. 

If  the  bowel,  however,  is  too  much  injured  to  have  a  reasonable  chance 
of  recovery,  or  if  the  intussusception  is  irreducible,  one  of  three  courses  must 
be  followed — either  the  bowel  must  be  opened  above  the  tumour  and  an 
artificial  anus  made,  the  invagination  being  left  to  itself,  or  the  intussus- 
ception must  be  resected  and  the  two  ends  of  the  gut  stitched  together,  or 
finally,  after  resection  the  two  ends  may  be  brought  out  of  the  wound  and 
fixed  to  its  edges,  an  artificial  anus  being  made.  The  plan  of  leaving  the 
intussusception  alone  has  no  advantages,  inasmuch  as  the  injured  bowel  will 
almost  certainly  act  as  an  irritant  and  set  up  peritonitis.  The  plan  of  re- 
section and  suturing  together  the  ends  of  the  bowel,  if  successful,  gives,  of 
course,  the  most  perfect  result  ;  but  it  is  open  to  the  objection  that  it  is  long 
and  tedious,  and  the  child  is  likely  to  die  of  exhaustion,  and,  further,  there  is 
danger  of  leakage  even  after  the  most  careful  suturing.  If  this  plan  "is 
adopted,  it  is  probably  wise  to  use  Barker's  plan  of  resection  of  the  intussus- 
ceptum from  within  the  gut,  or  one  of  the  many  other  modes  of  uniting  the 
ends  of  the  bowel  may  be  employed.  Of  these  that  by  Murphy's  button  is 
probabty  the  quickest  method  ;  but  in  the  absence  of  any  of  the  special  appli- 
ances, simple  direct  suture  by  Lembert's  method  may  be  employed.  The  least 
dangerous  course,  if  the  child  is  very  feeble,  is  to  resect  the  tumour  and  fix 
both  ends  of  the  gut  to  the  abdominal  wound.  Subsequently,  i.e.  after 
several  weeks,  should  the  child  recover,  an  attempt  may  be  made  to  restore 


Intussusception  1 4 1 

the  natural  channel  and  close  the  artificial  anus  liy  the  usual  method.  The 
ends  of  the  bowel  may  be  dissected  away  from  tlic  edges  of  the  wound  and 
united  to  one  another  by  sutures  or  other  method.  This,  though  a  less 
showy  plan  and  one  requiring  more  prolonged  treatment,  is  safer  at  the  time 
than  the  other  method  of  immediate  union  after  resection,  though  in  a  case 
where  the  child  appeared  well  able  to  bear  the  more  severe  operation, 
immediate  union  is  the  proper  course,  especially  if  suitable  appliances  are  at 
hand.  The  utmost  care  in  all  cases  must  be  taken  to  prevent  the  escape  of 
the  intestinal  contents  into  the  peritoneal  cavity :  this  is  managed  by 
emptying  the  segment  of  gut  dealt  with  before  opening  it,  and  keeping  it 
empty  by  pressure  of  an  assistant's  fingers  or  a  clamp,  such  as  a  pair  of 
forceps  shielded  with  soft  rubber  and  fixed  very  lightly  on  the  bowel,  so  as 
not  to  bruise  it,  or  a  better  and  simpler  plan  is  that  of  tying  a  piece  of 
rubber  tube  round  the  ends  of  the  gut.  All  blood  &c.  must  be  carefully 
cleaned  out  of  the  peritoneum. 

Given,  then,  a  case  of  acute  intussusception,  inversion  and  injection 
may  first  be  gently  tried  ;  should  these  means  be  successful  as  shown  by 
the  bowels  acting,  well  and  good  ;  if  after  injection  the  tumour  disappears, 
it  is  well  to  wait  for  a  few  hours  to  see  whether  the  bowels  are  relieved.  If 
injection  proves  successful,  the  child  should  be  kept  under  the  influence  of 
opium,  and  the  pelvis  raised  above  the  level  of  the  head.  If,  however,  the 
tumour  does  not  disappear,  or  if,  in  spite  of  its  disappearance,  or  of  course 
in  its  absence  from  the  first,  the  symptoms  persist,  immediate  laparotomy 
with  reduction  of  the  invagination,  if  possible,  should  be  performed,  and  if 
not  reducible  the  tumour  should  be  resected  and  dealt  with  by  one  of  the 
methods  mentioned.  The  balance  of  surgical  opinion  appears  to  lean 
towards  the  view  that  immediate  abdominal  section  is  the  safer  and  wiser 
course.  The  results  of  injection  are  uncertain,  its  use  is  dangerous,  and 
delay  in  reduction  of  the  intussusception  is  so  disastrous  that  probably  more 
lives  would  be  saved  by  immediate  operation  than  by  any  other  treatment. 
For  further  details,  we  must  refer  to  the  general  text-books  or  to  Mr.  Treves's 
work  on  Intestinal  Obstruction,  or  to  Mr.  D'Arcy  Power's  Hunterian  Lectures, 

1897. 

Chronic  intussusception  is  exceedingly  rare  in  children,  except,  perhaps, 
as  one  form  of  so-called  prolapse  of  the  rectum,  which  is  really  intussuscep- 
tion of  the  upper  into  the  lower  part  of  the  bowel.  A  chronic  invagina- 
tion may,  however,  occur  elsewhere  ;  its  duration  may  be  weeks  or  months  ; 
Treves  records  a  case  of  a  year's  standing  and  a  doubtful  one  of  many  years' 
duration.  We  have  had  a  child  under  the  joint  care  of  our  colleague 
Dr.  Hutton  and  ourselves  in  which  a  chronic  intussusception  of  the  ileo- 
cajcal  variety  existed  for  a  year,  and  which  ultimately  died  of  faecal  extrava- 
sation from  gangrene  found  at  the  time  of  abdominal  section.  The  whole 
tumour  was  soft  and  pulpy,  there  was  intermittent  constipation,  no  vomiting, 
tenesmus,  or  bleeding,  much  distension  with  visible  peristalsis,  at  times,  at 
others  a  flaccid  abdomen  ;  no  definite  tumour  was  to  be  felt  in  the  rectum 
or  abdomen,  and,  in  fact,  the  symptoms  in  this  case,  as  in  most  of  those  on 
record,  were  very  uncertain,  and  not  at  all  characteristic  of  intussusception. 
Enterotomy  or  resection  was  the  only  thing  that  could  have  relieved  this 
case,  and  if  the  symptoms  were  at  all  urgent  we  should  recommend  it  in 


142  Diseases  of  the  Digestive  System 

another  case,  reduction  of  the  invagination  being  quite  impossible.  The 
bowel  in  these  cases  sometimes  sloughs  away  as  in  the  acute  form.  In  the 
simple  rectal  form  the  prolapse  is  usuall}'  reducible,  and  if  so  can  be  cured 
by  rest,  avoidance  of  straining,  and,  if  necessary,  the  use  of  the  cautery  as  in 
other  cases.  It  is  of  the  utmost  importance  that  the  motions  should  be 
passed  in  the  recumbent  position,  and  should  be  kept  soft  by  doses  of  cod- 
liver  oil  or  by  olive-oil  enemata.  ( Vide  Rectal  Prolapse.)  We  have 
recently  (1895)  seen  with  Dr.  Cox  a  child  in  whom  there  were  symptoms 
suggestive  of  intussusception,  though  there  was  no  bleeding  or  tenesmus. 
There  was  obstruction,  with  a  palpable  oval  tumour  lying  on  the  right  side 
of  the  umbihcus,  and  closely  simulating  an  intussusception.  We,  however, 
came  to  the  conclusion  that  the  case  was  one  of  tubercular  mesenteric 
glands,  which  by  pressure  or  traction  caused  the  obstruction,  and  on  opening 
the  abdomen  this  view  proved  correct  ;  the  tumour  was  a  large  mass  of 
glands  caseating  and  breaking  down,  and  other  enlarged  glands  were  found. 
The  manipulation  relieved  the  obstruction,  but  the  child  was  too  ill  to  bear 
removal  of  the  glands,  and  died  a  few  days  later. 

We  have  recorded  in  conjunction  with  Dr.  Knowles  Renshaw  '  a  case  6f 
intussusception  of  the  vermiform  appendix  into  the  csecum  treated  by 
removal  of  part  of  the  appendix.  Reduction  was  only  partially  effected  even 
after  opening  the  caecum  and  pushing  out  the  intussusception  from  within. 
The  lumen  of  the  bowel  was  not,  however,  seriously  obstructed,  and  the 
child  completely  recovered.  Other  cases  of  this  condition  have  been  put  on 
record  by  Chaffey,  Pitts,  and  others.-'  Since  there  is  no  obstruction  in 
these  cases  the  symptoms  are  not  acute.  The  occurrence  of  an  intussusception 
through  a  persistent  Meckel's  diverticulum  has  been  already  mentioned. 

Chronic  Obstruction  of  the  Bowels. — Reference  has  already  been  made 
to  the  constipation  of  infants  and  older  children,  due  to  an  atonic 
condition  of  the  colon  or  a  chronic  intestinal  catarrh  ;  but  other  causes  of 
inactive  bowels  exist  which  are  attended  with  serious  inconvenience,  and 
even  fatal  results.  Occasionally  fibrous  bands  due  to  old,  perhaps  a  foetal 
or  to  tubercular  peritonitis,  mat  together  the  coils  of  intestine,  more 
especially  the  lower  part  of  the  ileum,  and  consequently  check  or  interfere 
with  the  peristaltic  action  of  the  bowels.  It  appears  also  that  occasionally 
the  sigmoid  meso-colon  and  meso-rectum  are  shorter  than  usual,  fixing  the 
lower  bowel,  and  perhaps  more  or  less  forming  a  kink  at  its  natural  curves, 
where  hardened  fteces  may  lodge  and  a  temporary  obstruction  take  place. 
A  fatal  case,  which  seems  to  have  been  due  to  this  cause,  is  recorded  by 
Dr.  Eustace  Smith,  the  patient  being  a  boy  of  8  years  who  died  shortly 
after  coming  into  hospital.  Whatever  may  be  the  cause,  cases  not 
infrequently  come  under  observation  where  the  child  has  suffered  from 
constipation  all  its  life,  large  accumulations  of  fasces  taking  place  in  the 
colon  which  have  to  be  removed  by  enemata,  and  where  the  bowels,  if  left 
to  themselves,  only  act  once  or  twice  a  week.  In  some  of  such  cases  an 
enormously  dilated  colon  has  been  found  after  death  with  superficial 
ulceration  of  its  mucous  membrane,  the  cause  of  such  dilatation  being  by  no 
means  clear.    In  two  of  these  cases  which,  by  the  kindness  of  Dr.  Wilkinson, 

'  Bf'it.  Med.  Jour.  June  1897. 

-  Vide  Treatment,  November  25,  1897. 


Chronic  Obstruction  of  the  Bozvels  143 

we  have  been  able  to  see,  the  distension  was  at  times  enormous.  In  one  we 
did  inguinal  colotomy,  and  found  the  intestine  full  of  frothy  fluid.  The  child 
died  shortly  after  the  operation.  In  one  instance  Mr.  Treves  removed  the 
colon  with  a  good  result.  It  must  not  be  forgotten  also  that  a  chronic  intus- 
susception may  exist  for  many  months,  and  give  rise  to  the  symptoms  of 
chronic  obstruction.  A  careful  examination  of  the  abdomen  should  be  prac- 
tised in  order  to^ascertain  the  presence  of  a  tumour,  and  to  determine  if  pos- 
sible its  nature,  whether  due  to  collections  of  hardened  faeces,  matting  of  the 
omentum  and  intestines,  as  in  chronic  peritonitis,  or  to  the  presence  of  an 
invaginated  bowel.  An  examination  of  the  rectum  should  always  be  made. 
The  possibility  of  obstruction  being  due  to  pressure  of  an  abscess  or  growth 
in  the  pelvis,  or  to  the  presence  of  a  foreign  body  in  the  bowel,  must  also  be 
borne  in  mind. 


144  Diseases  of  the  Digestive  System 


CHAPTER  VIII 

DISEASES   OF   THE   DIGESTIVE   SYSTEM — {C07ltilllied) 

Tubercular  Ulceration   of  Bovrel  and  IMIesenteric  Disease 

In  the  majority  of  cases  of  children  dying  of  tubercular  disease,  tubercular 
ulcers  are  present  in  the  intestines,  and  the  mesenteric  glands  are  enlarged 
and  '  cheesy '  on  section.  This  association  of  ulceration  of  the  intestines  with 
cheesy  mesenteric  glands  is  so  much  the  rule  that  it  is  impossible  to  separate 
the  two  clinically,  and  it  must  also  be  remembered  that  anatomically  the 
solitary  glands  and  Peyer's  patches  are  lymphatic  structures.  The  frequency 
with  which  these  lesions  complicate  phthisis  or  general  tuberculosis  is  shown 
by  the  fact  that  in  103  consecutive  post-mortems  made  at  the  General 
Hospital  for  Sick  Children,  Manchester,  on  children  of  all  ages  dying  of 
tuberculosis,  in  62  there  was  tubercular  ulceration  of  the  intestines,  in  71 
cheesy  mesenteric  glands,  in  55  both  ulcers  and  cheesy  glands  existed 
too-ether,  in  7  tubercular  ulcers  without  cheesy  glands,  in  16  cheesy  glands 
without  ulcers.  (See  also  Tuberculosis,  Chapter  XIII.)  These  numbers,  as 
far  as  the  frequency  of  tubercular  ulceration  is  concerned,  do  not  overstate 
the  fact,  as  it  is  far  more  hkely  that  the  presence  of  ulcers  in  the  intestines, 
especially  if  they  are  small,  should  be  overlooked,  than  their  frequency  over- 
rated. These  statistics  also  show  the  frequent  association  of  ulceration  of 
the  intestines  and  disease  of  the  mesenteric  glands,  though  this  association 
is  not  constant,  and  one  may  be  found  occasionally  without  the  other. 
Ulceration  may  exist  without  the  mesenteric  glands  joining  in  the  process, 
but  there  is  a  strong  probability,  amounting  almost  to  certainty,  that  if  ex- 
tensive ulceration  be  present  the  glands  will  be  found  to  be  affected.  On 
the  other  hand  it  is  certain  that  ulceration  is  not  the  necessary  precursor  of 
mesenteric  disease  ;  for  just  as  a  chronic  catarrh  of  the  nasal  mucous 
membrane  may  in  an  unhealthy  subject  set  up  glandular  enlargement 
and  abscess,  so  a  catarrh  of  the  intestine,  if  long  continued,  is  exceedingly 
apt  to  give  rise  to  mesenteric  disease.  Although  mesenteric  disease  is  so 
commonly  found  in  children  dying  with  a  widespread  distribution  of  tubercle, 
it  is  by  no  means  so  common  to  find  tubercular  disease  beginning  with 
symptoms  of  tabes  mesenterica,  as  is  commonly  believed,  for  in  practice  it 
is  constantly  found  that  infants  and  children  who  have  habitually  distended 
abdomens,  with  more  or  less  wasting,  are  put  down  as  suffering  from  '  con- 
sumption of  bowels.'  In  the  greater  number  of  these  cases  there  is  no 
mesenteric    disease,  but  a  chronic  and  obstinate  catarrh  of  the  intestines 


Tiibercular   Ulceration  of  Bowel  145 

which  is  perfectly  remediable,  liesides  the  \cry  frccjuent  association  of 
ulceration  and  mesenteric  disease,  chronic  tubercular  jjeritonitis  is  a  frequent 
complication. 

Infants  and  children  of  all  ages  suffer  from  tuberculosis,  of  the  intestines 
and  glands,  but  it  is  perhaps  less  common  before  the  age  of  one  year  than 
a.fter\vards.  The  common  cause  of  marasmus  in  infants  is  a  gastro-intestinal 
atrophy  rather  than  tubercular  disease,  such  infants  succumbing  before  the 
tubercular  process  is  set  up,  though  in  some  cases  cheesy  glands  may  be 
found.  It  has  just  been  noted  that  in  at  least  7o  per  cent,  of  cases  dying  of 
tuberculosis,  disease  of  the  mesenteric  glands  was  present,  and  in  rather 
more  than  55  per  cent,  tubercular  ulceration  was  associated  with  it  ;  it  is  of 
some  interest  and  importance  to  inquire  in  how  many  of  these  cases  was  the 
tuberculosis  of  the  intestine  and  glands  primary,  and  the  tubercular  lesions 
elsewhere  secondary ;  and  in  how  many  instances  the  tubercular  disease 
began  with  abdominal  symptoms.  A  primary  tuberculosis  of  the  intestine 
is  suggestive  of  infection  by  means  of  tubercular  bacilli  taken  in  food,  as, 
for  instance,  in  the  milk  from  a  cow  with  tuberculous  udder.  (See  TUBER- 
CULOSIS.) 

Of  the  103  fatal  cases  of  tuberculosis  referred  to  above,  in  13  or  about 
12  per  cent,  the  early  symptoms  were  referable  to  the  abdomen  ;  in  a  few  of 
the  cases,  symptoms  of  lung  mischief  were  absent  during  life,  and  the  lungs 
were  found  free  from  tubercle,  or  only  slightly  affected  ;  in  the  majority  of 
cases  the  physical  signs  and  symptoms  pointed  during  life  to  lung  compli- 
cations, which  supervened  sooner  or  later,  and  at  the  post-mortem  more  or 
less  extensive  pulmonary  lesions  were  found,  though  in  some  instances  these 
only  appeared  during  the  last  few  weeks  or  months  of  life.  Tubercular 
ulcers  are  most  frequently  found  in  the  ileum,  and  in  the  large  bowel,  especi- 
ally in  the  cKcum.  In  chronic  cases  they  may  be  very  extensive,  with  much 
matting  together  of  different  coils  of  intestine  and  of  the  omentum  by  peri- 
tonitis. The  walls  of  the  caecum  are  often  much  thickened.  The  ulcers,  if 
recent,  are  sharply  punched  out ;  if  chronic,  their  edges  are  thickened  and 
irregular,  mostly  running  across  the  gut.  The  mesenteric  glands  when 
affected  are  enlarged  and  cheesy  ;  sometimes  a  few,  at  other  times  nearly  all 
the  glands  seem  to  have  undergone  cheesy  changes  ;  occasionally  suppura- 
tion takes  place.  The  ulcers  may  cicatrise,  and  by  puckering  the  gut  give 
rise  to  some  obstruction  to  the  passage  of  the  intestinal  contents,  especially 
in  the  large  bowel  or  at  the  ceecum. 

Symptoms. — If  a  child  of  over  two  years  of  age  suffers  from  a  chronic 
looseness  of  the  bowels,  with  wasting  and  hectic,  there  is  a  strong  probability 
that  it  suffers  from  abdominal  tuberculosis.  This  probabihty  passes  more  or 
less  into  a  certainty  if  it  comes  of  a  tubercular  stock  and  presents  the  usual 
tubercular  aspect,  such  as  marked  pallor,  long  curved  eyelashes,  and  excessive 
growth  of  fine  downy  hair  upon  the  skin.  The  abdomen  is  usually  more  or 
less  distended  with  gas,  the  superficial  veins  are  enlarged,  there  may  be 
tenderness  on  deep  pressure,  and  perhaps  some  thickening  may  be  felt  over 
the  caecum,  or  some  matting  of  the  omentum.  The  symptoms  are  often 
varied  according  as  ulceration  of  the  bowels,  mesenteric  disease,  or  chronic 
peritonitis  is  extensively  present.  In  most  cases  of  tubercular  ulceration 
there  is  troublesome  diarrhoea,  though  it  must  be   borne  in  mind  that  this 

L 


146  Diseases  of  the  Digestive  System 

diarrhoea  in  many  cases  completely  stops  for  a  while,  or,  indeed,  may  be 
absent  from  first  to  last.  There  is  no  special  feature  about  the  diarrhoea  of 
tubercular  disease  ;  there  is  a  general  tendency  to  looseness,  and  cohc  may 
come  on  after  errors  in  diet,  or  directly  after  food  is  taken,  or  may  appear  to 
be  the  result  of  cold.  The  stools  are  mostly  liquid  and  brown  or  yellow  with 
an  excessive  quantity  of  mucus  and  perhaps  streaks  of  blood,  but  too  much 
stress  must  not  be  laid  upon  the  character  of  the  stools.  The  tongue  is 
usually  clean  and  red,  with  enlarged  and  congested  fungiform  papillae.  It  is 
of  course  necessary  to  carefully  examine  the  lungs  in  all  such  cases,  as  any 
confirmatory  evidence  of  tuberculosis  there  would  be  of  great  importance 
from  a  diagnostic  point  of  view.  The  course  of  such  cases  is  often  chronic, 
and  they  often  greatly  improve  for  a  while,  probably  on  account  of  the  intes- 
tinal catarrh  which  is  present  undergoing  improvement,  or  the  ulcers  may 
slowly  cicatrise  and  heal.  On  the  other  hand,  there  is  a  constant  risk  of  a 
tubercular  meningitis  supervening,  or  some  acute  lung'trouble  carrying  them 
off.  Sooner  or  later,  however,  the  diarrhoea,  wasting,  and  hectic  reappear, 
the  child  becomes  more  and  more  pallid,  the  abdomen  more  distended,  the 
feet  swollen,  and  the  face  puffy.  The  diarrhoea  at  the  last  is  often  constant, 
and  the  desire  to  go  to  stool,  only  a  little  mucus  or  liquid  faeces  passing, 
is  very  distressing  and  not  easily  relieved.  The  emaciation  at  the  last  is 
often  extreme.  When  symptoms  of  abdominal  tuberculosis  follow  on  those 
of  chronic  tuberculosis  of  the  lungs,  the  diagnosis  is  not  difficult,  and  a  more 
rapid  course  may  be  predicted.  When  the  tuberculosis  of  the  intestines 
is  primary  and  uncomplicated  with  other  trouble,  the  course  may  be  very 
chronic,  extending  over  several  years,  improvement  taking  place  from  time 
to  time. 

In  rare  cases  severe  hccmorrhages  may  occur  from  tubercular  ulceration 
of  the  intestines.  This  takes  place,  as  would  naturally  be  expected,  in  the 
acute  rather  than  in  the  chronic  cases,  as  in  the  late  cases  thickening  and 
cicatrisation  take  place.  We  have  known  fatal  haemorrhage  from  the  bowel 
to  take  place  from  a  tubercular  ulcer  of  the  ileum. 

In  the  following  case  there  was  severe  haematemesis,  and  some  dark 
blood  was  also  passed  by  stool.  The  case  was  puzzling,  as  at  the  time  the 
vomiting  of  blood  took  place  there  was  nothing  in  the  lungs  or  abdomen 
to  suggest  tuberculosis. 

Acute  Tuberculosis  ;  Ulcers  in  the  Jejunum  ;  Severe  Hceviatemesis. — William  T. ,  aged 
10  years.  He  was,  it  was  stated,  always  a  strong  boy  till  a  fortnight  before  his  admission, 
when  he  complained  that  he  was  lame  in  his  right  leg ;  both  knees  were  painful  and 
swollen.  Admitted  June  18.  He  was  a  well-nourished  boy  ;  all  the  organs  were  normal ; 
his  appetite  was  bad  ;  there  was  no  diarrhoea.  The  right  knee  was  swollen  ;  there  was  a 
suspicion  of  early  hip  disease  on  the  right  side.  The  evening  temperature  reached  102°  ; 
the  evening  temperature  continued  raised  a  degree  or  two  for  a  few  days,  and  then  became 
normal.  He  complained  for  the  next  week  or  two  of  great  pain  in  his  knee.  On  July  11, 
after  having  had  a  good  dinner,  he  suddenly  vomited  a  quantity  of  bright  blood  with  large 
clots,  and  quickly  became  blanched  ;  twice  during  the  day  he  again  vomited  dark  blood. 
There  was  some  tenderness  and  resistance  on  the  left  side  of  the  abdomen,  just  below  the 
ribs.  He  remained  fairly  well  till  July  18,  when  he  again  vomited  some  half-pint  of  blood 
and  mucus  ;  there  were  large  quantities  of  dark  blood  in  his  stools.  July  28. — He  has  wasted 
much  in  the  last  few  weeks  ;  there  is  no  cough  or  diarrhoea.  From  this  date  till  bis  death 
the  temperature  was  hectic,  varying  from  100°  to  103°  ;  rales  were  heard  in  his  lungs^ 


Tubercular   Ulceration  of  Boivel  i^y 

especially  at  the  apices,  and  it  was  evident  he  was  suffering  from  acute  tuberculosis.  He 
gradually  became  extremely  emaciated  ;  there  were  no  more  haemorrhages.  He  never 
suffered  from  any  diarrhoea.  Death  occurred  September  27.  At  the  post-mortem,  both 
lungs  were  studded  with  clusters  of  tubercles,  becoming  caseous  at  the  right  apex  ;  the 
mediastinal  glands  were  caseous.  The  stomach  was  healthy  ;  the  mesenteric  glands  were 
swollen,  but  not  caseous  ;  there  were  some  large,  recent,  sharply  cut  tubercular  ulcers  in 
the  middle  of  the  jejunum,  and  numerous  others  in  the  ileum  and  large  bowel.  Miliary 
tubercles  on  the  spleen  and  liver.     Early  tubercular  hip  disease. 

In  those  cases  where  the  mesenteric  glands  are  chiefly  affected  the 
symptoms  are  still  less  definite,  though  this,  as  has  been  pointed  out,  is  not 
often  the  case,  as  varying  degrees  of  tubercular  ulceration  of  the  intestines 
and  chronic  cicatrising  peritonitis  are  apt  to  be  present.  The  symptoms  are 
usually  those  of  chronic  intestinal  catarrh,  perhaps  without  marked  diarrhoea, 
with  wasting  and  hectic.  It  must  be  remembered  that  a  distended  abdomen 
which  is  chronically  in  this  condition,  with  some  wasting  and  an  evening 
exacerbation  of  temperature,  does  not  necessarily  mean  mesenteric  disease, 
any  more  than  the  signs  of  a  chronic  pneumonia  are  necessarily  to  be  inter- 
preted as  the  signs  of  tubercle  ;  we  only  infer  in  both  cases  that  tuber- 
culosis exists  if  we  get  confirmatory  evidence  elsewhere.  A  history  of 
tubercle  in  the  family,  the  steady  progress  of  the  disease,  wasting,  great 
pallor  and  hectic,  would  help  the  diagnosis.  The  supposed  large  glands 
should  be  carefully  felt  for,  taking  care  not  to  mistake  ficces  in  the  large 
bowel  or  indurations  of  the  mesentery  or  caecum  for  enlarged  glands.  The 
fingers  should  be  laid  on  the  abdomen  below  the  umbilicus  and  pushed  well 
in,  and  gently  moved  about ;  the  mesenteric  glands  lie  deeply,  can  rarely  be 
distinctly  felt,  they  are  movable,  and  of  size  varying  from  hazel  nuts  to 
walnuts.  If  the  abdomen  is  distended  with  gas,  even  large  groups  of  glands 
may  exist,  and  yet  not  be  felt.  An  early  diagnosis  is  rarely  possible  by  dis- 
covery of  enlarged  glands  ;  it  is  only  towards  the  close  that  they  can  usually 
be  felt,  when  the  tonus  of  the  abdominal  inuscles  is  diminished  and  the 
intestines  more  or  less  collapsed. 

Diag?iosis. — A  child  with  a  temperature  raised  a  few  degrees  at  night, 
with  distended  abdomen,  chronic  diarrhoea  which  resists  treatment,  and 
has  produced  wasting  and  marked  pallor,  is  probably  the  subject  of 
tubercular  ulceration  of  the  intestines.  If,  at  the  same  time,  local  indura- 
tions can  be  felt  in  the  region  of  the  caecum  or  in  other  places,  or  if  there  are 
signs  of  tubercular  disease  in  the  lungs,  the  diagnosis  becomes  still  more 
probable.  Moreover  the  diarrhoea  probably  persists  in  spite  of  liquid  diet, 
rest  in  bed,  and  astringents,  and  is  only  temporarily  kept  in  check  by  opium. 
Mesenteric  disease  is  much  more  frec|uently  diagnosed  than  discovered ^(^j'/ 
mortem.  A  progressive  wasting  due  to  chronic  intestinal  catarrh  or  gastro- 
intestinal atrophy  is  frequently  attributed  to  caseous  degeneration  of  the 
mesenteric  glands,  and  a  fatal  termination  is  looked  upon  as  inevitable.  It 
is  well,  however,  to  bear  in  mind  that  mesenteric  disease  is  uncommon  before 
eighteen  months  or  two  years  of  age,  and,  moreover,  great  wasting  may  be 
due  to  intestinal  catarrh  without  mesenteric  disease.  It  is  but  seldom  that 
enlarged  glands  can  be  felt  ;  the  diagnosis  mainly  depends  upon  the  signs  of 
tubercle  elsewhere  in  the  body  and  upon  the  family  history.  If  there  has 
been   much    diarrhoea    with    hectic,   and    symptoms   of  chronic  peritonitis, 

L  2 


148  Diseases  of  tlie  Digestive  System 

followed  by  extreme  wasting,  thei^e  is  good  reason  to  suspect  mesenteric 
disease. 

Treatment. — ^The  treatment  of  tubercular  ulceration  and  mesenteric 
disease  is  the  treatment  of  tuberculosis  in  general.  Fresh  air  and  careful 
dieting  are  all-important.  The  special  treatment  consists  in  keeping  the 
diarrhoea  in  check,  while  nourishing  food  easy  of  assimilation  is  being  sup- 
plied to  the  patient.  The  class  of  foods  must  be  selected  from  those  which 
contain  much  nutriment  in  little  bulk,  such  as  eggs,  fish,  meat,  fats,  milk, 
rather  than  foods  containing  large  quantities  of  starch  and  sugar.  If  there 
is  but  little  diarrhoea,  milk  may  be  allowed  in  moderate  quantities,  but  the 
amount  taken  must  not  be  excessive  if  much  looseness  of  the  bowels  exists, 
as  too  much  fluid  taken  is  apt  to  aggravate  the  diarrhoea.  In  all  stages  of 
the  disease  minced  underdone  meat,  whether  chicken,  beef,  or  mutton  chop, 
is  of  great  value.  The  child's  portion  may  be  taken  from  red  juicy  meat 
found  close  to  the  bone  in  a  large  joint  of  roast  beaf  It  should  be  finely 
minced,  cut  as  fine  as  it  is  possible  to  cut  it,  and  gravy  poured  over 
it  before  it  is  taken.  Of  this,  large  quantities  will  be  taken  readily  by  the 
children,  some  crumbs  of  stale  bread  being  given  with  it ;  but  even  small 
■quantities  of  starch  are  apt  to  disagree  and  give  rise  to  flatulence.  An  &%'g 
or  part  of  an  &'g'g  beaten  up  in  milk  may  be  given  once  or  twice  a  day.  The 
diarrhoea  is  best  kept  in  check  by  careful  dieting,  avoidance  of  more  food 
than  the  child  can  digest,  and  if  excessive,  the  food  for  a  while  must  consist 
almost  entirely  of  pounded  underdone  meat  or  meat  juice.  Small  doses  of 
opium  combined  with  mercury  and  chalk  may  be  given.     (F.  41,  42.) 

In  the  later  stages  small  enemata  of  laudanum  and  starch  may  be  re- 
quired, but  too  often  the  diarrhoea  is  quite  uncontrollable.  Opium  fomenta- 
tions are  useful.  If  the  diarrhoea  is  due  to  the  presence  of  indigestible  food, 
laxatives  such  as  a  powder  containing  rhubarb  and  soda  should  be  given. 
Cod-liver  oil,  either  as  an  emulsion  or  in  combination  with  other  tonics,  is 
useful  in  all  stages  except  when  diarrhoea  is  excessive.     (F.  43,  44.) 

Cong-enital  Obstruction  of  the  Bowels. — It  is  not  an  uncommon  cir- 
cumstance for  a  newly  born  infant  to  suffer  from  complete  obstruction  of 
the  bowels  :  passing  no  meconium,  though  the  rectum  may  be  normal,  and 
shortly  after  being  put  to  the  breast  it  may  vomit,  first  milk,  then  bile, 
and  finally  meconium.  In  the  meantime  the  abdomen  becomes  dis- 
tended, the  face  pinched,  and  the  infant  dies  in  a  few  hours,  or  perhaps 
lingers  for  a  few  days.  At  \h&  post-mortem  various  obtructive  lesions  may- 
be found.  There  may  be  a  stenosis  of  the  duodenum,  jejunum,  or  more 
frequently  the  ileum,  the  gut  perhaps  being  narrowed  or  even  reduced  to  a 
mere  band  of  fibroid  tissue  which  runs  along  the  free  edge  of  the  mesentery 
for  perhaps  several  inches,  and  opens  out  again  into  normal  bowel  lower 
down  ;  this  cicatrisation  of  a  portion  of  bowel  may  have  been  produced  by  a 
foetal  peritonitis,  or  it  is  the  result  of  a  mal-development.  In  the  following- 
case  it  was  apparently  the  latter  : 

Congenital  Occlusion  of  the  Duodenum  (Dr.  T.  B.  Grimsdale's  case). — The  mother 
•was  a  healthy  woman  who  had  had  five  children  previously.  The  first  was  still-born ;  the 
four  others  all  suffered  from  symptoms  of  obstruction  and  died  on  the  third  day  after 
birth.  The  sixth  child  appeared  healthy  and  well  nourished  at  birth,  and  for  the  first  two 
days  seemed  quite  well.     For  the  last  two  days  it  was  a  peculiar  colour — a  sort  of  orange 


Obstruction  of  the  Bozvels  149 

I)iii[j1c  tint.  It  only  vomited  once  shortly  before  death  ;  it  was  convulsed  before  death. 
At  the  autopsy  the  stomach  and  upper  part  of  the  duodenum  were  distended  with  fluid  ; 
the  duodenum  was  found  to  terminate  in  a  cul-de-sac  about  two  inches  from  the  pylorus. 
The  rest  of  the  intestines  were  well  formed  though  small;  the  Ijile  duct  opened  into  the 
duodenum  below  the  obstruction. 

In  the  following  singular  case  there  was  an  obstruction  of  the  jejunum, 
presumably  clue  to  a  fcttal  peritonitis  and  possibly  some  chronic  inflamma- 
tory lesions  after  birth  : 

Congenital  Ohstniction  of  ihc  Jejunum;  Dilated  Stomach  and  Duodenum. — W.  M., 
aged  15  years,  seen  with  Mr.  C.  R.  Graham,  of  Wigan.  His  mother  gave  the  following 
history  :  He  was  nursed  at  the  breast  for  some  months,  and  during  this  time  he  was  sub- 
ject to  periodical  attacks  of  severe  vomiting  ;  these  attacks  were  much  more  severe  than 
infants  are  usually  subject  to.  The  vomiting  began  immediately  after  birth  ;  the  vomited 
matters  consisted  of  curd  and  bile.  These  attacks  of  vomiting  have  occurred  at  intervals 
of  a  week  or  two  all  his  life.  On  more  than  one  occasion  the  attacks  have  been  so  severe 
and  long  continued  that  his  life  was  despaired  of.  He  has  vomited  as  much  as  six  to 
eight  pints  in  one  night.  He  went,  on  one  occasion,  a  voyage  to  the  Mediterranean,  but 
had  to  be  landed  on  the  first  opportunity,  as  the  constant  vomiting  had  so  exhausted  him 
that  his  life  was  in  danger.  Sometimes  he  would  suffer  from  colic  and  nausea  but  did  not 
\omit.  Errors  of  diet,  excitement,  or  worry  all  seemed  to  excite  an  attack.  A  physical 
examination  showed  a  dilated  stomach ;  the  abdomen  was  also  more  or  less  distended. 
The  symptoms  and  physical  examination  pointed  to  a  dilated  stomach,  secondary  to  some 
congenital  obstruction  in  the  upper  part  of  the  bowels.  The  vomiting  attacks  continued 
during  the  next  four  years,  up  to  the  time  of  his  death,  when  he  was  nineteen  years  old. 
We  are  indebted  for  details  of  his  last  illness  to  Dr,  Sutcliffe,  of  Jersey,  where  he  died. 
He  seemed  in  his  usual  health  on 'December  6,  1893,  and  joined  in  a  game  of  football. 
The  same  evening  he  had  one  of  his  usual  vomiting  attacks,  which  was  more  severe 
than  usual,  and  Dr.  Sutcliffe  was  sent  for.  When  seen  on  December  8,  he  was  evidently 
suffering  from  acute  obstruction  of  the  bowels  :  the  vomiting  was  continuous,  and  nothing 
was  passed  per  rectum.  There  was  intense  collapse.  Death  took  place  on  the  fourth  day 
of  his  illness.  Post-mortem  made  by  Mr.  Graham  and  ourselves  :  The  body  was  that  of 
a  well-grown  but  thin  youth.  On  opening  the  abdomen  the  small  intestines  were  seen  to 
be  intensely  congested  and  of  a  dark  purple  colour  ;  there  was  some  lymph  on  the  surface  ; 
the  parietal  layer  of  the  peritoneum  was  much  injected.  The  whole  of  the  small  intestines 
were  evidently  strangulated,  there  being  a  complete  volvulus  ;  the  last  foot  or  so  of  the 
ileum  was  wound  two  or  three  times  round  the  upper  part  of  the  jejunum,  the  latter  being 
twisted  on  itself,  so  that  the  jejunum,  mesentery,  and  blood-vessels  were  strangulated  ;  the 
caecum  was  dragged  upwards  out  of  its  place.  The  immediate  cause  of  death  was  the 
volvulus,  probably  the  result  of  severe  vomiting.  A  further  examination  showed  the  cause 
of  his  vomiting  attacks.  The  stomach  and  duodenum  were  immensely  dilated  and  hyper- 
trophied,  the  duodenum  looking  like  a  second  stomach  ;  at  the  junction  of  the  duodenum 
with  the  jejunum,  the  gut  was  bound  down  and  surrounded  by  fibroid  adhesions  for  some 
six  inches,  and  one  spot  was  contracted  so  as  only  to  admit  the  forefinger.  The  fibroid 
mattings  were  presumably  the  result  of  some  inflammatory  lesion  taking  place  before  birth. 

In  another  instance  we  were  called  to  see  a  patient  of  26  years  of 
age  with  intestinal  obstruction.  Before  seeing  him  we  were  told  as  a  re- 
markable peculiarity  that  he  had  gone  on  growing  until  the  time  of  his 
illness,  i.e.  his  26th  year.  We  found  a  tall,  thin,  ill-developed,  youthful- 
looking  man,  dying  of  intestinal  obstruction.  On  opening  the  abdomen 
there  was  general  peritonitis,  the  intestines  were  inextricably  matted 
together  by  old  adhesions  as  well  as  by  recent  lymph.  Nothing  could 
be  done.     The  testes  though  in  the   scrotum  were   very  small   and  unde- 


1 50  Diseases  of  the  Digestive  System 

veloped,  and  there  were  practically  no  signs  of  pubert)'.  It  appears 
likel)'  that  the  arrest  of  development  was  the  result  of  the  old  and  probably 
fcEtal  peritonitis  which  was  ultimately  the  cause  of  the  obstruction.  The 
abnormal  prolongation  of  the  period  of  growth  was  probably  due  to  the 
same  lack  of  development  of  adult  characters.  He  died  at  the  time  of  the 
operation. 

In  a  few  cases  a  twist  in  the  lower  end  of  the  ileum  has  been  found.  In  , 
rare  instances,  a  new  growth  or  hernia  has  occurred,  or  a  knuckle  of  bowel 
has  been  found  tied  up  by  some  band  or  persistent  omphalo-mesenteric  duct. 
Obstruction  of  the  bowels  in  infants  a  few  weeks  or  months  old  may  be 
due  to  a  congenital  lesion  which  has  caused  a  partial  obstruction,  which  is 
rendered  complete  by  the  impaction  of  hard  curdy  feculent  matters. 

In  all  cases  of  vomiting  with  signs  of  obsti'uction  of  the  bowels,  a  care- 
ful examination  of  the  anus  and  rectum  should  be  made      (See  also  p    142.) 

Imperforate  Anus. — The  lower  segment  of  the  large  intestine,  including 
the  sigmoid  flexure  and  rectum,  is  very  liable  to  important  malformations. 

In  the  first  place  there  may  be  mere  malposition,  the  sigmoid  flexure  de- 
scending on  the  right  side  or  in  the  middle  line  instead  of  on  the  left  ;  this 
would  not  necessarily  give  rise  to  any  inconvenience  during  health,  and 
would  be  mainly  of  importance  should  there  be  any  disease  of  the  bowel  in 
later  life. 

The  more  immediately  important  conditions  are  the  various  forms  of 
obstruction  of  the  lower  bowel  from  want  of  development  of  some  part  of  it, 
or  the  presence  of  abnormal  openings  from  imperfect  differentiation  of  the 
digestive  and  genito-urinary  segments  of  the  cloaca. 

Several  varieties  of  malformation  are  found.  There  may  be  a  well-formed 
anus,  but  communication  between  this  and  the  rectum  may  be  cut  off  by  the 
presence  merely  of  a  membrane  which  has  persisted  from  the  time  when  the 
epiblastic  involution — proctodeum — dipped  in  to  meet  the  intestine.  {Imper- 
forate rectum.)  Sometimes  the  rectum  itself  is  deficient  altogether  or  for  a  vary- 
ing distance,  the  anus  also  being  undeveloped.  In  other  instances  the  rectum 
is  well  formed,  but  the  anus  is  absent.  [Impejforate  anus.)  In  these  varieties 
there  is  no  external  opening  at  all,  and  the  meconium  is  retained.  Some- 
times the  anus  is  undeveloped,  and  the  rectum,  instead  of  ending  blindly,  opens 
into  the  anterior  or  genito-urinary  segment,  i.e.  into  the  urethra  or  bladder, 
or,  much  more  commonly  in  the  female,  into  the  vestibule,  not  into  the 
vagina,  as  is  commonly  stated  ;  the  vaginal  orifice  in  these  cases  is  nearly 
always  in  our  experience  seen  in  front  of  the  rectal  outlet.  We  have  only 
once  met  with  a  case  of  the  irectum  opening  into  the  vagina  itself ;  this  was 
in  a  child  kindly  sent  us  by  Di'.  Cullingworth,  who  thinks  it  is  not  an 
uncommon  condition.  Bodenhamer,  out  of  287  cases,  found  85  opening 
into  the  vulva  or  urinary  tract,  while  in  53  there  was  no  anus  and  the  rectum 
ended  blindly  ;  these  are  the  two  most  common  types. 

Occasionally  a  '  tablike  fold  of  skin  '  passing  from  the  scrotum  to  the 
coccyx  obstructs  but  does  not  close  the  anus  (Cripps).  Edge  has  recorded  a 
more  complete  case  where  the  anus  was  double  and  the  rectum  imperforate. 
We  have  met  with  a  case  where  a  single  anus  led  up  to  a  double  gut  above. 
Rarely  there  is  an  unnatural  anus  in  the  groin  or  in  communication  with  the 
bladder,  or,  as  in  a  case  of  Erichsen's,  a  fistula  below  the  umbilicus  ;  scrotal. 


Imperforate  Amis  151 

penile,  and  perineal  fistuhe  ha\  e  also  been  met  with  as  well  as  congenital 
stricture  of  the  rectum  which  was  not  actually  imperforate.  (  Vide  PROLAP.SU.s 
Recti.)  As  a  less  important  condition  mere  tightness  of  the  anus  may  also 
occur. 

When  the  anus  is  present,  but  there  is  no  communication  with  the  bowel, 
the  malformation  is  often  overlooked  at  first,  and  it  is  thought  that  the  infant  is 
simply  constipated  ;  in  such  cases  purgatives  are  often  given  and  the  child's 
distress  much  increased.  Constant  crying,  distension  of  the  abdomen  with 
visible  intestinal  coils,  and  subsecjuently  vomiting  and  collapse  come  on,  and 
unless  an  examination  with  the  finger  is  made  and  the  obstruction  discovered 
the  child  dies  exhausted.  On  examination  it  will  be  found  that  the  finger 
can  only  be  passed  a  very  short  distance  ;  if  the  rectum  is  developed  and 
there  is  only  a  membranous  septum,  the  bulging  of  the  gut  as  the  child 
strains  will  be  plainly  felt,  but  should  the  bowel  end  higher  up  this  sensation 
may  not  be  distinguishable. 

Where  the  anus  is  absent  and  the  rectum  ends  just  above  it,  as  according 
to  Cripps  it  usually  does,  though  in  our  own  experience  the  common  condi- 
tion is  a  well-marked  proctodeeum  but  no  rectum,  the  bulging  will  often  be 
readily  made  out,  but  if  the  rectum  ends  higher  up  there  may  be  no 
impulse  ;  in  such  cases  the  perineum  is  narrow  and  the  pelvic  outlet  smaller 
than  it  should  be.  When  there  is  no  anus  the  rectum  is  generally  nearer  the 
surface  than  when  an  anus  is  developed,  but  the  rectum  ends  Mindly. 

Where  the  rectum  ends  high  up  in  the  pelvis,  a  fibrous  cord  may  be 
prolonged  downwards  in  the  position  of  the  natural  bowel  ;  this  cord  was 
thought  by  Mr.  Curling  to  represent  the  rectum  obliterated  by  intra-uterine 
ulceration  ;  its  presence,  however,  is  not  constant.' 

When  the  rectum  ends  in  the  urethra  there  is  a  passage  of  fluid  fasces  and 
flatus  by  the  urethra,  together  with  absence  of  the  natural  orifice.  Subse- 
quently, if  the  child  survives,  there  is  much  trouble  from  obstruction  of  the 
urethra  by  ftecal  matter  and  from  irritation  set  up  by  the  decomposed  urine. 
Kelsey  -'  points  out  that  if  the  opening  is  into  the  bladder  the  meconium  is 
mixed  with  the  urine,  while  if  it  is  urethral  the  bowel  contents  may  escape 
independently  of  the  urine.  When  the  rectal  outlet  is  within  the  vestibule  the 
bowels  may  be  sufficiently  relieved  for  the  deformity  to  escape  notice,  and 
there  may  be  no  impairment  of  health ;  indeed,  the  presence  of  such  malforma- 
tion may  remain  unknown  until  adult  life.  In  many  cases,  however,  though 
the  opening  is  sufficient  for  the  escape  of  the  fluid  or  soft  fasces  of  child- 
hood, it  is  not  large  enough  to  allow  the  passage  of  solid  motions,  and 
obstruction  arises  later  on.  There  is  no  incontinence  of  faeces  in  these 
patients,  the  internal  sphincter  preventing  involuntary  escape. 

As  in  so  many  other  congenital  malformations,  a  large  number  of  chil- 
dren the  subject  of  these  deformities  do  not  survive  birth.  Where,  however, 
a  living  child  is  found  to  have  no  outlet  at  all  for  its  intestinal  contents, 
immediate  treatment  is  of  course  necessary,  although  it  is  said  that  patients 
have  grown  up  and  relieved  the  bowels  by  periodical  vomiting  of  ffeces. 
As  soon  then  as  the  deformity  is  recognised,  a  decision  must  be  come  to  as 
to  what  is  the  best  mode  of  relief 

1    Vide  Parker,  Path.  Soc.  Trans.  1884.  -  Archives  of  PcBdiatrics. 


152  Diseases  of  the  Digestive  System 

Treatment. — When  a  thin  septum  alone  closes  the  gut  a  simple  crucial 
incision,  using  a  speculum  if  necessary,  and  subsequent  dilatation  with  a 
bougie  or  the  finger,  is  all  that  is  required.  The  child,  if  it  survives,  may  in 
no  way  suffer  afterwards,  though  we  have  seen  a  case  of  a  girl  of  10  or  12 
years  old  who  had  been  operated  on  in  infancy  and  had  not  got  perfect 
control  over  the  bowels. 

Where  the  separation  between  the  rectum  and  the  surface  is  greater, 
bulging  of  the  distended  gut  should  be  carefully  felt  for  and  an  incision  made 
just  in  front  of  the  coccyx  and  carried  down  to  the  bowel,  which  should  then 
be  freely  opened  and  brought  down  and  stitched  to  the  skin,  unless  there  is 
so  great  tension  that  the  stitches  are  not  likely  to  hold,  in  which  case  the 
opening  shonld  be  packed  with  gauze  to  keep  it  patent,  or  a  large  drainage 
tube  inserted. 

If  no  bulging  can  be  felt,  an  attempt  to  reach  the  bowel  should  still  be 
made  by  a  similar  incision,  and  the  dissection  should  be  carefully  carried  up- 
wards, keeping  well  back  in  the  hollow  of  the  sacrum  and  feeling  from  time  to 
time  for  the  bowel.  As  it  is  most  important  that  the  child  should  strain, 
chloroform  should  only  be  given  during  the  first  steps  of  the  operation, 
and  fortunately  this  is  ,the  most  painful  part  of  it.  With  a  sirnilar  object 
it  has  been  advised  to  delay  operation  until  the  bowels  are  distended  ;  this  is 
not,  however,  a  wise  course.  If  the  gut  is  found,  it  should  be  treated  as  in 
other  cases,  or  if  it  cannot  readily  be  brought  down,  it  must  be  left  but  kept 
patent  in  a  similar  way,  or  a  tube  may  be  kept  in  through  which  fseces  can 
pass.  Amussat  and  Verneuil  resected  the  coccyx  and  lower  part  of  the 
sacrum  in  order  to  bring  the  gut  to  the  surface. 

Should  it  be  impossible  to  reach  the  bowel  from  below  by  dissection, 
which  may  be  carried  to  a  depth  of  an  inch  and  a  half,  in  no  case  must 
any  blind  puncturing  with  a  trocar  in  hopes  of  finding  the  gut  be  employed  ; 
by  such  means  there  is  much  more  likelihood  of  puncturing  the  peritoneum, 
especially  as  it  usually  descends  lower  than  in  normal  anatomy.  Either 
Littre's  operation  of  opening  the  bowel  in  the  groin  or  Amussat's  (Callisen's) 
lumbar  operation  must  be  performed.  As  there  is  some  uncertainty  in 
all  these  cases  as  to  the  course  of  the  bowel,  and  as  in  a  certain  proportion 
the  colon  lies  in  the  middle  line  or  to  the  right  side,  it  is  wiser  on  the  whole  to  do 
Littre's  operation.  The  danger  of  opening  the  peritoneum  is  not  so  unequal 
in  the  two  plans  as  might  be  thought,  since  there  is  often  a  mesentery 
in  these  cases,  and  the  anus  is  much  more  conveniently  placed  for 
self-management  in  after  life  ;  there  is  Httle  choice  in  the  matter  of  danger 
between  the  two.  Littre's  operation  then  should  be  selected.  The  operation 
consists  in  making  a  vertical  or  oblique  incision  about  two  inches  in  length 
in  the  left  groin  above  and  a  little  external  to  the  middle  of  Poupart's 
ligament  ;  a  vertical  incision  is  probably  the  best,  since,  if  the  sigmoid 
flexure  does  cross  to  the  right,  a  slight  upward  prolongation  of  the  incision 
will  enable  the  surgeon  to  reach  it.  The  abdominal  wall  having  been  cut 
through  and  the  peritoneum  opened,  the  distended  bowel  will  present  at  the 
opening  and  should  be  picked  up  with  forceps,  and  treated  as  in  the  ordinary 
colotomy  operation.'     If  the  child  can  bear  the  delay  in  opening  the  bowel, 

^  For  a  description  of  the  operation  we  must  refer  to  the  general  text-books. 


Imperforate  A  nus  1 5  3 

the  operation  should  be  done  in  two  stages  as  in  gastrostomy  ;  to  avoid 
leakage  Cripps  suggests  the  use  of  a  coarse  thread  in  stitching  the  gut  to  the 
edge  of  the  wound  ;  the  use  of  a  round  sewing  needle  answers  better. 

Edmund  Owen  has  six  times  performed  Littre's  operation,  twice  success- 
fully ;  three  of  his  cases  died  from  the  operation  being  too  late,  peritonitis 
existing  at  the  time.  In  three  or  four  of  the  instances  in  which  we  have  done 
inguinal  colotomy  the  result  was  perfectly  satisfactory  ;  the  children  got  quite 
well  for  a  time,  but  it  is  probably  rare  for  such  patients  to  survive  childhood. 
It  has  been  suggested  that  after  opening  the  sigmoid  flexure  in  the  groin,  a 
probe  should  be  passed  downwards  and  an  anus  made  in  the  natural  position 
with  the  guidance  of  the  probe.  Owen's  two  successful  cases  of  Littre's 
operation  died  after  the  performance  of  the  second  operation,  but  Byrd  and 
Kronlein  have  been  successful.' 

Curling's  statistics  and  opinion  are  much  in  favour  of  the  inguinal 
operation  ;  Cripps'  figures  are  inconclusive.'-  Huguier's  operation  of  opening 
the  gut  in  the  right  groin  on  the  ground  of  the  more  frequent  position  of  the 
colon  on  the  i-ight  side  than  the  left  is  not  supported  by  Girald^s'  statistics, 
quoted  by  Holmes,  where  in  431  autopsies  the  colon  was  in  its  normal  position 
in  396  instances  ;  in  eighty  of  these  Littre's  operation  had  been  performed, 
and  in  every  case  the  sigmoid  flexure  was  on  the  left  side.  Atkin,  of  Sheffield, 
records  a  case  in  which  the  small  intestine  was  opened  by  the  ing^uinal  ope- 
ration, the  whole  colon  being  rudimentary  ;  ^  and  our  colleague,  Mr.  White- 
head, tells  us  he  operated  in  the  left  loin  on  one  occasion  and  found  at  the 
post-mortem  that  the  caecum  had  been  opened.^ 

We  have  opened  a  coil  of  large  intestine  by  right  inguinal  colotomy  in 
an  adult,  and- found  that  it  was  the  sigmoid  flexure  and  not  the  ascending 
colon  that  had  been  secured. 

Cripps'  table  gives  the  following  results  : 

Of  16  cases  of  inguinal  colotomy        ....  11  died 

„     3        „         lumbar         „ 2  „ 

,,17        „         puncture     „ 14  „ 

„     8        ,,         resection  of  the  coccyx         .         .         •  5  ,) 

„  39        ,,          perineal  incision           .         .         .         .  14  „ 

,,14        ,,         operation  for  vaginal  (i.e.  vulvar)  anus  i  „ 

„     3  miscellaneous  cases             .         .         .         .         ■  3  ?> 

Bodenhamer  records  eight  recoveries  out  of  tAventy-five  Littre's  opera- 
tions. 

The  deaths  are  mainly  due  to  peritonitis,  or  failure  of  relief. 

Where  there  is  a  fistulous  opening  between  the  rectum  and  the  bladder 
or  urethra,  Littre's  operation  should  be  performed,  unless  the  gut  can  be 
reached  from  the  perineum,  when  possibly  the  communication  with  the  urinary 
tract  may  close  spontaneously.  When  the  unnatural  anus  opens  in  the 
vulva,  in  the  cases  we  have  seen  it  has  usually  been  by  an  orifice  in  the  side 
of  the  distended  rectum  and  not  by  a  terminal  opening  ;  that  is,  the  rectum  has 

1    V^ide  Kelsey,  Arch,  of  Fcsdiatrics,  February  1885  ;  also  Goede  vide  Cripps. 

-   Firfe  also  Erckelen,  Arch.  f.  Klin.  Chir.,  Langenbeck,  1879. 

5  Lancet,  January  31,  1884.  *  Pi  lore  advised  opening  the  caecum. 


154  Diseases  of  the  Digestive  System 

been  pouched  and  projecting  below  the  vulvar  aperture.  In  such  conditions 
a  bent  probe  should  be  passed  through  the  orifice  into  the  gut  and  made  to 
press  against  the  perineum  just  in  front  of  the  coccyx.  An  incision  is  then 
made  upon  the  probe,  the  rectum  freely  opened  and  treated  in  the  usual 
way.  Great  care  must  be  taken  to  keep  the  new  aperture  patent,  otherwise 
it  is  prone  to  contract  and  the  fteces  continue  to  pass  both  ways.  In  some 
cases  it  is  said  that  the  vulvar  orifice  will  contract  and  close  of  itself 
(Holmes).  In  our  own  cases  we  have  not  found  this  to  occur,  and  in  one  of 
them  we  pared  the  edges  of  the  vestibular  opening  and  sutured  them  ;  no 
union,  however,  resulted,  and  we  afterwards  laid  open  the  perineum,  dissected 
away  the  gut  from  the  vestibular  wall,  stitched  it  carefully  to  the  skin,  and  then 
sewed  up  the  perineum,  with  a  successful  result ;  the  patient  was  about 
6  years  old.  In  another  instance  we  performed  the  same  operation  in  a 
child  of  9  months,  but  it  died  some  weeks  later  of  inanition.  We  have  had 
a  third  successful  case  in  which  power  of  retention  seems  well  preserved. 
Dieffenbach  appears  to  have  been  the  first  to  adopt  this  plan,  which,  how- 
ever, is  often  called  Rizzoli's  operation.  It  is,  we  think,  well  to  wait  until 
the  child  is  two  or  three  years  old  before  doing  the  second  operation. 

One  of  the  difficulties  we  have  met  with  in  these  cases  is  that  of  keeping 
the  bowels  regular  even  when  there  is  quite  a  free  opening  ;  this  we  believe 
to  be  due  to  imperfect  muscular  action,  though  the  muscular  coat  of  the 
bowel  is  hypertrophied  in  some  of  these  cases.  Enemata,  castor-oil  emul- 
sion, and  occasional  more  active  purges  are  required  under  these  circum- 
stances. Sometimes  when  the  case  is  one  of  vulvar  anus  a  collection  of 
hard  f^ces  is  found  in  the  intestine  above  at  the  time  of  operation  ;  this 
requires  removal,  as  the  child  is  often  unable  to  void  it  even  Avhen  a  good- 
sized  aperture  has  been  made. 

Deformities  of  the  XTmbilicus. — In  some  cases  of  extroversion  of  the 
bladder  there  is  no  trace  of  an  umbilicus  to  be  seen  in  after  life,  the  scar 
being  lost  in  the  malformed  abdominal  wall.  In  other  cases  the  umbilicus 
is  abnormally  large — that  is,  a  considerable  part  of  the  abdominal  wall 
is  formed  by  the  structures  of  the  cord,  and  sloughs  away  when  the  cord 
shrivels  up  so  that  an  actual  deficiency  of  the  abdominal  wall  results.  In 
two  cases  of  this  condition  we  have  seen  that  were  operated  upon,  one  by 
Mr.  Howse  and  one  by  ourselves,  a  portion  of  the  liver  protruded  through  the 
opening  and  was  covered  only  by  the  sloughing  tissue.  In  our  own  case  we 
dissected  away  the  dead  part  and  closed  the  abdominal  openings  by  sutures, 
but  without  success  ;  in  a  third  case,  under  our  care,  the  part  was  simply 
protected  from  irritation  and  left,  but  this  child  also  soon  died.^  The  fre- 
quent presence  of  the  liver  in  the  hernia  has  given  rise  to  the  name  of 
Hepatomphalos,  but  the  stomach  and  other  viscera  are  often  included  in  the 
protrusion. 

At  the  third  month  of  intra-uterine  life  there  is  still  a  coil  of  intestine 
lying  in  the  umbilical  cord  outside  the  abdominal  cavity  ;  should  this  condi- 
tion persist,  a  true  congenital  umbilical  hernia  is  found.     The  importance  of 

1  Underwood  records  a  case  of  recovery  in  which  the  treatment  consisted  in  poulticing, 
and  Tanner  and  others  have  had  successful  cases.  In  a  case  of  Brodie's  Path.  Soc. 
Trans,  vol.  xv. ,  besides  the  hepatomphalos,  there  was  diaphragmatic  hernia  with  defi- 
ciency of  the  pericardium,  and  a  coil  of  bowel  lay  in  contact  with  the  heart. 


Dcfoniiiiics  of  the    UinbilicuS  i  5  5 

this  fact  is  that  in  hgaturiny  the  cord  the  gut  might  be  inckided  in  the  hga- 
turc  and  strangulated,  a  mishap  that  has  actually  occurred.  In  slighter 
cases  there  is  onl)-  a  small  protrusion  standing  out  from  the  abdominal  wall 
much  like  the  end  of  a  glove  finger  ;  the  bowel  is  reducible  and  the  treat- 
ment is  that  of  an  ordinary  umbilical  hernia.  In  other  instances,  owing  to 
persistence  of  the  vitello-intestinal  duct,  Meckel's  diverticulum  remains 
open,  and  passing  up  to  the  umbilicus  may  open  there,  giving  rise  to  feecal 
fistula,  as  in  a  case  of  our  own  where  a  ligature  round  the  protrusion, 
followed  by  the  application  of  strapping  to  draw  together  the  sides  of  the 
orifice,  procured  closure  of  the  fistula.'  Edmund  Owen  advises  emptying 
the  bowel  by  free  purging  and  subsequent  administration  of  opium,  thus 
giving  time  for  the  fistula  to  close  ;  he  applies  a  dry  pad  over  the  fistula  and 
leaves  it  undisturbed.  Success  has  followed  this  treatment,  but  it  appears 
to  be  applicable  to  older  children  rather  than  to  infants.  A  plastic  operation 
on  the  usual  lines  for  the  cure  of  faecal  fistula  would  be  the  proper  treatment 
in  a  troublesome  case.  For  patent  urachus  dr'c.  vide  SURGERY  OF  the 
Urinary  Organs,  vide  also  Diseases  of  the  Navel. 

Congenital  hiatus  of  the  abdominal  wall  may  occur  in  other  parts  besides 
the  umbilicus  from  simple  failure  of  closure  of  the  ventral  laminae.  Of  this 
extroversion  of  the  bladder  is  an  instance.  In  some  cases  the  recti  fail  to 
meet  one  another  in  the  middle  line,  and  ventral  hernia  may  result  with  great 
weakness  of  the  abdominal  wall. 

Well-arranged  pads  applied  by  means  of  a  belt  must  be  employed  to 
prevent  protrusion,  or  probably  in  some  cases  it  would  be  justifiable  to  cut 
down  upon  and  stitch  together  the  margins  of  the  aperture,  an  operation 
not  of  a  veiy  serious  nature,  and  not  of  course  necessitating  any  injury  to  the 
peritoneum. 

Umbilical  Hernia. — Umbilical  hernia  in  children  may  be  congenital  or 
acquired  ;  in  the  congenital  form  it  is  sometimes  due  to  persistence  of  the  foetal 
condition  where  a  coil  of  bowel  lies  outside  the  abdomen  ;  in  other  cases, 
as  already  pointed  out,  it  is  the  result  of  failure  of  closure  of  the  ventral 
laminae. 

The  acquired  form  usually  appears  within  the  first  few  months  of  life  ;  in 
this  case  the  mpture  protrudes  not  through  the  centre  of  the  scar,  which  is 
occupied  by  the  fibrous  remains  of  the  vessels,  but  usually  above  it  or  even 
through  an  independent  opening  in  the  lineaalba.  Astley,  however,  believes 
that  the  protrusion  is  generally  through  the  ring.  Both  forms  of  hernia  are 
readily  reducible  and  usually  consist  of  small  intestine  ;  the  amount  of 
protrusion  varies  from  a  mere  convexity  of  the  navel  to  a  prominent  glove- 
finger-like  outgrowth. 

The  treatment  consists  in  applying  a  flat  pad  of  wood  or  poroplastic  felt 
about  the  size  of  a  penny  and  two  or  three  times  as  thick  ;  this  pad  should 
be  covered  with  flannel  and  fixed  over  the  umbilicus  by  a  broad  band  of 
strapping  encircling  the  body  or  by  a  soft  webbing  belt  ;  we  prefer  the 
former  as  more  efficient  and  less  likely  to  slip,  though  it  is  not  so  comfort- 
able as  the  belt.  If  the  pad  is  worn  constantly  for  from  one  to  three  months, 
according  to  the  age  of  the  child,  the  hernia  is  usually  '  radically  cured.'      In 

1  Vide  Diseases  of  the  Navel — Umbilical  Polypus. 


156  Diseases  of  the  Digestive  System 

cases  which  obstinately  resist  treatment  the  orifice  should  be  cut  down  upon 
and  sutured.  A  case  of  irreducible  umbilical  hernia  containing  omentum 
was  successfully  operated  on  by  Roocroft  in  a  girl  of  14  years  ;  ^  but  it  is 
clear  that  most  cases  of  umbilical  hernia  in  children  are  cured,  since  the 
condition  is  hardly  ever  seen  in  young  adults.  We  have  had  occasion  to  close 
by  operation  a  median  ventral  hernia  in  a  child.  The  result  was  successful. 
Xng-uinal  Hernia. — Inguinal  hernia  is  met  with  in  childhood  in  the 
following  varieties  : 

1.  The  funicular  process  of  peritoneum  remains  widely  open  and  in  free 
communication  with  the  cavity  both  of  the  peritoneum  and  tunica  vaginalis  : 
a  hernia  descending  into  this  cavity  is  a  true  congenital  hernia,  or  hernia  of 
the  tunica  vaginalis  (Teale). 

2.  The  tunica  vaginalis  may  be  shut  off  from  the  funicular  process  at  the 
upper  part  of  the  testicle  ;  a  hernia  coming  down  into  the  patent  process  is 
called  a.  funicular  hernia,  or  hernia  into  the  funicular  process. 

'  3.  When  the  same  condition  as  in  (2)  exists,  but  the  hernia  instead  of  de- 
scending along  the  canal  of  the  funicular  process  pushes  down  a  separate 
pouch  of  peritoneum  behind  the  process,  the  hernia  is  called  infantile  or 
encysted.  The  same  name  is  given  to  cases  where  the  funicular  process  is 
obliterated  at  the  internal  ring  or  just  above  the  testicle,  and  the  septum 
is  pushed  down  and  invaginated  into  the  lower  part  of  the  process.  In  the 
former  case,  in  cutting  down  upon  the  bowel  from  the  front  three  layers  of 
peritoneum,  viz.  two  funicular  and  one  sac  proper,  will  be  found  in  front  of 
the  gut  ;  in  the  second  case  two  layers  will  overlie  the  bowel. 

4.  An  ordinary  acquired  hernia  may  be  met  with.  Hernia  may,  of  course, 
be  complete  or  incomplete— that  is,  it  may  descend  into  the  scrotum  or  only 
distend  the  canal  or  bulge  at  the  internal  ring. 

The  first  and  second  forms  are  much  the  commonest,  and  it  is  usually 
impossible  to  be  certain  which  is  present  unless  the  parts  are  exposed  by 
operation.  Where  the  testicle  is  completely  wrapped  round  by  the  hernia 
it  is  probably  congenital ;  where  the  testicle  remains  a  distinct  boss  upon  the 
surface  of  the  hernia  it  may  be  fimicular,  though  it  is  not  by  any  means 
always  so.  We  believe  the  funicular  variety  is  the  more  frequent.  Infantile 
or  encysted  hernia  can  only  be  recognised  by  operation,  but  it  may  be  sus- 
pected if,  after  reduction  of  a  hernia,  an  unusual  amount  of  thickening  along 
the  cord  remains,  or  if  there  is  a  hydrocele  of  the  cord  or  an  infantile  hydro- 
cele in  conjunction  with  a  reducible  hernia.  Fortunately,  an  exact  diagnosis 
of  these  conditions  from  one  another  is  not  of  much  importance. 

Hernia  may  develop  at  any  age  ;  it  is  sometimes  noticed  immediately  after 
birth  ;  in  other  instances  it  comes  down  later  when,  from  failure  of  health,  or 
bronchitis,  or  whooping  cough,  the  muscular  walls  of  the  abdomen  become 
relaxed,  and  are  in  addition  overstrained  by  coughing,  violent  crying,  strain- 
ing in  defaecation,  micturition,  &c.  So  common  is  it  for  straining  in  micturi- 
tion to  bring  down  a  hernia,  that  it  is  quite  certain  that  phimosis  is  a  most 
fertile  cause  of  rupture.'-  The  presence  of  a  calculus  or  worms  acts  in  the 
same  way.     Hernia  very  commonly  accompanies  ectopia  vesica?. 

i  Lancet,  August  2,  1884. 

-  An  important  fact  first  pointed  out  by  Mr.  J.  A.  Kempe. 


Iii"iiinn/  Hernia 


157 


As  is  well  known,  inguinal  hernia  is  sometimes  met  with  in  female  chil- 
dren, though  not  nearly  so  commonly  as  in  boys.  Of  112  unselected  cases 
of  hernia  seen  in  our  out-patient  department,  there  were — 

In  males  .      57  right  inguinal,  12  left  inguinal,  16  double,  and  9  umbilical. 
In  females       4     „  ,,  5     „  ,,         no       „  „    9  (?  10)  „ 

Mr.  Leader  Williams  tells  us  that  in  his  experience  m  the  Maternity  Depart- 
ment of  St.  Mary's  Hospital,  Manchester,  umbilical  hernia  is  by  far  the 
commonest  variety,  and  this  is  no  doubt  true  of  the  first  {&^n  weeks  in  life. 

Most  commonly  an  inguinal  rupture  in  a  child  contains  small  intestine 
with  or  without  omentum,  perhaps  most  commonly  without.  Other  parts  of 
the  intestinal  canal  are,  however,  not  rarely  found.  We  have  many  times 
during  operation  found  the  CcECum  and  vermiform  appendix  in  a  hernia,  and 
not  rarely  the  appendix  can  be  very  distinctly  felt  through  the  coverings 
without  an  operation. '  The  ovaries  in  girls  and  the  bladder  in  either  sex  are 
sometimes  protruded. 

Generally  a  rupture  is  easily  reducible,  but  often  it  is  necessary  to  make 
the  child  lie  down  before  it  readily  goes  back  ;  it  then  often  does  so  sponta- 
neously. Violent  crying  will  sometimes  make  it  quite  impossible  to  safely 
reduce  a  hernia,  and  the  child  must  be  quieted  or  anaesthetised  before 
reduction. 

It  must  be  remembered  that,  though  as  a  rule  hernise  are  opaque,  a 
tightly  distended  rupture  consisting  only  of  bowel,  and  that  full  of  flatus,  in 
a  thin-skinned  child  will  be  distinctly  translucent ;  this  fact  was,  we  believe, 
first  pointed  out  by  Mr.  Howse,  and  we  have  several  times  seen  it. 

Various  abnormal  conditions  may  complicate  hernia  ;  thus  the  testis  may 
be  entirely  retained  or  have  imperfectly  descended  on  the  same  side.  A 
vaginal  hydrocele  or  hydrocele  of  the  cord  may  coexist  with  a  hernia,  or  fluid 
as  in  a  congenital  hydrocele  may  distend  the  sac  of  a  congenital  hernia.  The 
rupture,  of  course,  may  be  single  or  double,  and  sometimes  of  a  different 
species  on  the  two  sides.  We  have  seen  a 'funicular '  and  a  'congenital' 
hernia  on  opposite  sides  in  the  same  child.  Children  the  subject  of  hernia 
are  undoubtedly  often  affected  with  intestinal  disturbance,  which  appears  to 
be  sometimes  at  least  due  to  the  hernia.  It  has,  however,  been  suggested 
by  Lane  that  thelhernia  is  due  to  the  intestinal  trouble,  and  it  is  undoubtedly 
true  that  marasmic  children  with  chronic  indigestion  and  irregular  and  often 
constipated  bowels  not  uncommonly  have  hernias  which  are  not  readily  cured 
till  the  nutrition  is  improved. 

Ruptures  in  children  are  occasionally  irreducible  ;  when  this  is  due  simply 
to  straining,  as  already  pointed  out,  the  difficulty  is  easily  got  over  in  other 
cases  the  hernia  may  be  obstructed  by  its  contents  as  in  adults  ;  again, 
adhesions  to  the  sac  or  to  the  testicle  or  matting  together  of  bowel  to 
bowel,  or  bowel  to  omentum,  may  prevent  reduction.  In  one  of  our  cases  a 
large  hernia  was  made  irreducible  lay  the  presence  of  tuberculous  mesenteric 
glands  which  had  evidently  enlarged  after  their  descent,  and  it  was  only 
after  removal  of  some  of  these  and  enlargement  of  the  rings  that  the  rupture 

'  Vide  papers  in  the  Brit.  Med.  Jour.  vol.  i.  1887,  by  Mr.  F.  Treves,  and  also  by  one 
■  of  the  present  writers. 


158  Diseases  of  the  Digestive  System 

could  be  reduced  ;  the  child  recovered,  but  evidence  of  tuberculosis,  of 
course,  remained. 

It  is  somewhat  rare  for  a  hernia  to  become  strangulated  in  childhood. 
We  have,  however,  met  with  several  such  cases  ;  they  differ  in  no  respect 
from  the  similar  condition  in  the  adult,  but  considering  the  extreme  tender- 
ness of  the  tissues  in  children  immediate  operation  is  the  wisest  course  in 
preference  to  treatment  by  ice,  or  more  than  gentle  and  momentary  taxis  ; 
we  have  known  a  child  die  of  the  injury  done  to  a  coil  of  intestine  which 
was  reduced  before  the  child  was  seen  by  us,  and  could  only  have  been 
strangulated  for  a  few  hours.  The  youngest  cases  with  which  we  are 
acquainted  were  one  of  three  weeks  by  Halsewood,i  and  another  successful 
one  of  our  own,  and  one  of  four  weeks  by  Maunder.  The  sac  always 
requires  opening,  since  the  neck  itself  forms  the  constricting  part.  Some- 
times in  an  hour-glass  sac  the  constriction  may  be  in  the  scrotum. 

The  treatment  of  hernia  in  children  resolves  itself  into  three  questions  — 
first,  the  removal  of  all  causes  tending  to  produce  rupture,  such  as  cough, 
phimosis,  &c.  ;  secondly,  treatment  by  apparatus ;  and  lastly,  operations. 

Ruptures  in  children  sometimes  get  well  of  themselves  without  treatment, 
or  simply  by  keeping  the  child  lying  down  and  avoiding  disturbance  of  its 
temper  and  bowels.  In  other  instances  circumcision  will  prevent  further 
descent  of  hernia  by  removing  the  source  of  straining. 

Failing  these  means,  the  wisest  plan  is  at  once  to  provide  a  well-fitting 
truss,  a  matter  which  should  be  seen  to  by  the  surgeon  himself,  and  not  left 
to  an  instrument  maker.  The  truss  must  be  worn  night  and  day  without  any 
intermission,  never  being  removed  on  any  account  for  washing  or  any  other 
purpose  except  to  put  another  on  ;  this  is  necessary,  because  the  truss  is  in 
children  used  to  cure  rupture,  and  not  merely  to  palliate  it  as  in  adults.  When 
it  is  absolutely  necessary  to  change  a  truss,  the  new  one  must  be  got  ready, 
the  finger  slipped  beneath  the  old  one  to  keep  pressure  upon  the  canal  and 
then  the  truss  changed,  the  child  being  kept  on  its  back  and  soothed  to  pre- 
vent crying.  During  the  treatment  the  skin  must  be  carefully  watched  and 
kept  dry  and  unirritated  by  the  free  use  of  boric  acid  powder  ;  this  can  be 
dusted  beneath  the  truss  without  removing  it.  A  httle  judicious  packing  with 
absorbent  wool  will  serve  to  take  pressure  off  any  tender  part.  Almost  any 
hernia  during  the  first  year  of  life  that  can  be  kept  up  without  once  coming 
down  for  three  months  will  be  permanently  cured  ;  after  the  first  year  a 
longer  time  is  required. 

The  ordinary  flat-pad  trusses  do  very  well  if  the  parents  can  afford  to  fre- 
quently renew  them,  but  they  get  stiff  and  hard,  and  the  springs  soon  rust 
and  rot  with  the  frequent  soakage  of  urine,  so  that  they  have  to  be  frequently 
changed,  and  a  duplicate  should  always  be  at  hand  in  case  of  sudden  giving 
way.  One  descent  of  hernia  undoes  all  the  preceding  treatment ;  this  is  the 
cardinal  rule  to  impress  upon  the  mother  or  nurse.  The  inflatable  and  the 
glycerine  pad  rubber  trusses  we  have  found  useful  and  satisfactory  when 
carefully  managed,  and  they  are  not  affected  by  urine  nearly  so  rapidly  as  the 
common  truss,  but  they  require  careful  inspection  from  the  first,  as  they  are 
often  imperfectly  made,  and  flaws  or  tears  are  soon  fatal  to  them.     The  hard 

1  Lancet,  Dec.  1884. 


Inguinal  Hernia  1 59 

rubber  truss  is  sometimes  spoken  well  of ;  we  have  not  tried  it.  Celluloid  or 
gum  trusses  are  good.  If  from  bad  management  a  sore  is  produced  by  truss 
pressure,  careful  padding  will  often  avoid  the  necessity  of  leaving  off  the 
truss  ;  but  with  proper  attention  and  care  that  the  truss  spring  is  not  too 
strong,  it  seldom  occurs. 

Hydrocele  and  orchitis  we  have  more  than  once  seen  as  the  result  of 
wearing  a  truss  ;  in  such  cases  we  may  be  sure  that  the  spring  is  too  strong, 
and  a  different  truss  must  be  applied.  Spica  bandages,  wool  trusses,  &c. 
are  inefficient  substitutes  for  a  good  truss.  The  pad  of  the  truss  should  be 
flat  and  not  convex,  and  peaked  trusses  are  never  required  :  the  object  is  to 
prevent  the  hernia  from  entering  the  canal,  not  merely  to  cover  up  the 
rupture. 

When  a  fair  trial  has  been  given  to  trusses,  different  ones  being,  if 
necessary,  employed,  and  all  sources  of  irritation  have  been  removed  and 
still  the  rupture  cannot  be  kept  up,  an  operation  for  its  permanent  cure 
should  be  performed  ;  it  is  of  course  required  in  only  a  small  percentage  of 
cases. 

Of  all  the  various  plans,  the  one  we  think  simplest  and  as  good  as  any, 
and  the  only  one  we  shall  describe,  consists  in  making  a  free  incision  over 
the  canal  and  upper  part  of  the  scrotum,  cutting  down  to  the  sac,  reducing  the 
hernia,  closing  the  neck  of  the  sac  and  passing  silk  sutures  through  the  walls 
of  the  canal.  To  do  this  the  sac  must  be  opened  and  the  finger  passed  into 
the  abdomen  to  make  sure  that  the  canal  is  clear  and  to  guide  the  needle. 
The  needle,  which  must  be  in  a  handle,  is  passed  through  one  side  of  the 
canal,  and  guided  by  the  finger  is  brought  out  at  the  ring  ;  it  is  threaded 
with  silk  and  withdrawn,  then  unthreaded  and  passed  through  the  other  side, 
then  threaded  with  the  other  end  of  the  same  silk  and  again  withdrawn  ;  two 
or  three  sutures  are  passed  in  this  way  till  it  is  felt  that  there  are  enough  to 
close  the  canal,  the  threads  are  then  tied.  One  edge  of  the  sac  close  up  to 
the  threads  is  then  picked  up  and  threaded  upon  the  needle,  and  successive 
portions  of  the  surface  of  the  sac  are  pinched  up  and  transfixed  (like  thread- 
ing them  upon  a  skewer)  until  the  other  edge  is  reached  ;  the  needle  is  then 
threaded  with  catgut  or  silk  and  withdrawn,  leaving  the  ligature,  which  when 
tied  puckers  up  the  sac  into  closely  applied  folds  which  soon  adhere,  and  the 
sac  is  thoroughly  obliterated  ;  by  this  means  all  trouble  and  disturbance  in 
separating  the  sac  from  the  cord  is  avoided,  and  the  closure  is  quite  firm  and 
complete.  Sometimes  we  ligature  the  sac  before  closing  the  canal  ;  this  is 
not  quite  so  easy,  and  it  is  not  a  matter  of  importance.  The  wound  should 
be  closed,  and  will  heal  by  primary  union.  The  silk  requires  careful  pre- 
paration ;  if  not  thoroughly  sterilised,  a  troublesome  sinus  is  likely  to  form, 
and  the  suture  finally  comes  away.  We  prefer  to  select  the  particular  mode 
of  operation  most  suited  to  the  case,  rather  than  to  confine  ourselves  to  any 
one  method  exclusively.  There  is  sometimes  a  great  deal  of  swelling  after 
the  operation,  but  this  gradually  subsides  and  should  be  looked  upon  as  a 
good  sign  of  firm  consolidation.  For  the  methods  of  managing  complications 
of  the  operation  we  must  refer  to  the  ordinary  text-books,  for  undescended 
testis  to  the  chapter  on  that  subject.  An  omental  sac  may  be  met  with  ;  we 
have  seen  a  very  perfect  instance.  The  management  of  such  cases  and  of 
adhesions  differs  in  no  way  in  the  child  from  that  of  similar  conditions  in  the 


i6o  Diseases  of  the  Digestive  System 

adult.     It  is  better  not  to  allow  a  truss  to  be  worn  after  the  operation  unless 
there  is  some  special  reason  for  it. 

The  operation  is  not  free  from  risk  and  not  always  successful ;  we  have 
had  one  death  from  peritonitis  coming  on  some  time  after  the  operation,  and 
have  had  to  operate  more  than  once  in  several  cases.  In  the  fatal  case  the 
canal  was  perfectly  closed  and  the  peritoneal  surface  almost  undimpled. 
The  cause  of  failure  is  chiefly  a  thin  and  flaccid  condition  of  the  abdominal 
muscles,  which  cannot  be  made  to  form  a  firm  barrier. 

Femoral  hernia  in  children  is  very  rare,  we  have  never  seen  a  case  ;  one 
recorded  by  Sabourin  in  a  premature  female  infant  was  readily  cured  by  a 
truss.  E.  Owen  saw  one  in  a  boy  of  lo  years  out  of  748  cases  of  femoral 
hernia.'     Diaphragmatic  hernia  is  occasionally  met  with. 

Prolapsus  Recti. — Slight  degrees  of  prolapse  of  the  rectum  are  common 
in  children  and  are  often  only  transitory,  occurring  perhaps  once  or  twice  and 
not  again  ;  the  more  severe  forms  are  much  rarer. 

Prolapse  of  the  rectum  consists  in  protrusion  of  more  or  less  of  the 
rectal  wall  through  the  anus.  The  slight  and  most  common  form  is  simply 
a  pushing  out  of  a  ring  of  mucous  membrane,  which  is  readily  reducible  and 
often  only  comes  down  when  the  child  strains.  In  other  cases  the  whole  of 
the  rectal  coats  from  mucous  membrane  to  peritoneum  may  be  protruded. 

The  first  variety  of  prolapse  is  usually  about  half  an  inch  long  and  appears 
as  a  red  mucous  ring  with  radiating  folds  diverging  from  the  central  orifice  ; 
the  mucous  and  cutaneous  surfaces  shade  off  into  one  another  at  the  margin  of 
the  protrusion.  The  second  form  is  larger,  reaching  from  one  to  two  inches 
in  length,  and  is  often  conical  in  shape,  its  base  being  at  the  anus  ;  the  folds 
are  not  radial  but  annular,  running  round  the  prolapsed  part ;  the  orifice  is 
central,  and  on  passing  the  finger  into  it,  it  is  evident  that  the  whole  thickness 
of  the  bowel,  and  not  merely  mucous  membrane,  is  involved  in  the  prolapse. 
Sometimes  this  form  of  protrusion  reaches  much  larger  dimensions,  even  six 
inches  in  length,  and  in  such  cases  necessarily  a  large  pouch  of  peritoneum 
is  carried  down,  and  this  is  more  extensive  on  the  anterior  than  the  posterior 
aspect  of  the  bowel.  In  one  case  that  we  examined /cii-/  mortem  there  was 
a  definite  diverticular  pouch  with  a  sharp  lunated  edge  projecting  from  the 
recto-vesical  hollow  down  the  anterior  wall  of  the  rectum  ;  it  seemed  to 
us  probable  that  the  presence  of  a  coil  of  bowel  in  this  pouch  would  have 
much  to  do  with  keeping  down  the  prolapse.'^  Not  only  small  intestine  but 
the  ovaries  even  may  be  found  in  this  peritoneal  pouch,  which  then  becomes 
the  sac  of  a  rectal  hernia  ;  the  characteristic  gurgling  or  the  presence  of  a 
solid  body  felt  on  manipulating  the  wall  of  the  protrusion  may  give  a  clue  to 
the  extent  of  the  disease.  Rectal  hernia  sometimes  comes  down  behind 
the  bowel,  or  may  even  protrude  through  a  gap  in  the  muscular  coats. 
(Kelsey.)  This  variety  of  prolapse  is  sometimes  curved  as  a  result  of 
traction  by  the  mesocolic  fold  of  peritoneum  or  the  attachment  of  the  rectum 
to  the  vagina.  (Van  Buren.)  In  it  also  the  mucous  and  cutaneous  surfaces 
shade  off  into  one  another,  though  the  transverse  folds  of  mucous  membrane 
on  the  surface  of  the  prolapse  may  somewhat  obscure  the  line  of  junction. 

1  Lancet,  June  6,  1884. 

-  The  specimen  from  this  case  is  in  the  Owens  College  Museum  ;  this  definite  pouching 
is,  so  far  as  we  know,  undescribed  hitherto. 


Prolapsus  Recti  i6i 

A  so-called  third  form  of  prolapsus  recti,  where  the  upper  part  of  the 
rectum  or  the  sigmoid  flexure  is  invaginated  into  the  bowel  below  and  pro- 
trudes from  the  anus,  is  recognised  by  its  size  and  by  the  presence  of  a  sulcus 
l^etvveen  the  prolapse  and  the  anal  margin.  This  condition,  however,  is  more 
naturally  considered  as  an  intussusception  than  as  a  prolapse. 

The  mucous  surface  of  the  protruded  gut  may  be  nearly  natural,  but  more 
often  is  excoriated  and  coated  over  with  a  thick  slimy  mucus  ;  it  sometimes 
becomes  congested  and  may  even  slough  from  irritation  or  constriction  by 
the  sphincter,  though  in  most  cases  the  anus  is  so  lax  and  patulous  that  the 
existence  of  a  sphincter  at  all  is  hardly  felt  by  a  finger  passed  within  the 
opening.  Bleeding  to  small  amounts  often  occurs,  and  there  is  much  mucous 
discharge. 

The  motions  come  away  freely,  but  the  irritation  and  discharge  weaken 
the  child,  and  he  loses  flesh  and  health.  In  most  cases  the  prolapse  is  re- 
ducible with  more  or  less  difficulty,  but  often  it  returns  immediately  pressure 
is  taken  off ;  in  others  it  remains  up  until  the  child  strains  from  any  cause  and 
then  redescends  ;  in  others  again  the  protrusion  after  a  time  becomes  irre- 
ducible from  matting  together  of  the  parts  and  from  congestion. 

Where  a  rectal  hernia  exists  it  is  subject  to  all  the  conditions  of  an 
ordinary  inguinal  hernia,  i.e.  it  may  be  reducible  or  strangulated,  &c.i  Occa- 
sionally the  prolapse  sloughs  and  fgecal  fistula  results,  or  the  wall  may  burst 
in  attempts  at  reduction. 

The  causes  of  prolapsus  recti  are  many,  though  it  is  obvious  that  there 
must  be  some  weakness  of  the  sphincter  and  levator  ani  or  relaxation  of  the 
rectal  walls  in  these  cases,  or  prolapse  would  be  much  more  frequent  than  it  is. 
Any  condition  that  produces  violent  and  constant  straining  may  bring  on 
prolapse  in  a  child  predisposed  to  it.  The  child  is  generally  miserable  and 
weakly  when  seen,  but  this  is  no  doubt  partly  the  result  of  the  irritation. 
Phimosis,  contracted  meatus  urinarius,  stone  in  the  bladder,  cystitis,  con- 
stipation, diarrhoea,  worms,  polypus  recti,  violent  coughing,  &c.  all  may  cause 
prolapse.  Boeckel  believes  stricture  of  the  rectum  to  be  a  cause,  and  in 
one  case  we  found  a  tight  annular  stricture  of  the  rectum  about  one  inch 
from  the  anus  ;  this  only  admitted  the  tip  of  the  index  finger  in  a  child  of 
about  three  years  old  ;  the  stricture  apparently  formed  the  apex  of  the 
prolapse,  and  may  possibly  have  been  the  result  rather  than  a  cause  of  the 
protrusion. 

The  diagtiosis  of  prolapsus  recti  is  easy  where  the  protrusion  is  large  ;  the 
only  doubtful  point  is  what  extent  of  rectal  wall  is  included  in  it.  If  small 
it  can  only  be  mistaken  for  piles  or  polypus  ;  the  former  are  exceedingly  rare 
in  children  and  never  form  a  complete  ring,  the  latter  is  of  course  a  single 
isolated,  usually  pedunculated  sweUing  ;  a  mistake  can  only  occur  from  lack 
of  examination.  Kelsey  lays  it  down  that  any  prolapse  over  2^  inches  in 
length  contains  peritoneum,  while  the  presence  of  a  sulcus  serves  to  dis- 
tinguish between  the  second  form  and  the  rectal  intussusception.  The 
direction  of  the  folds  and  the  size  distinguish  between  the  first  and  second 
varieties. 

The  treatment  of  prolapse  consists  first  in  removing  the  cause  of  strain- 
ing, next  the  child  should  be  kept  rigidly  lying  down  in  bed  ;  the  protrusion 

^    Vide  Kelsey,  in  an  elaborate  paper  in  Archives  of  Pcediatrics,  1885. 

M 


1 62  Diseases  of  the  Digestive  System 

must  be  reduced  each  time  it  comes  down,  and  if  it  constantly  recurs  an 
attempt  should  be  made  to  keep  it  up  by  a  pad  and  T-bandage,  or  by 
strapping"  the  buttocks  together  with  a  broad  piece  of  plaster.  The  bowels 
should  be  kept  easily  open  so  as  to  avoid  straining,  and  it  is  sometimes 
useful  to  support  the  sides  of  the  anus  during  defcccation  by  pressure  or  by 
drawing  the  skin  tightly  to  one  side  ;  as  advised  by  Van  Buren,  the 
motions  should  be  passed  into  a  napkin  without  the  child  being  allowed  to 
sit  up. 

Enemata  of  cold  water  or  astringents,  tannin,  quassia  (2-4  oz.  of  the 
infusion),  oak  bark,  sulphate  of  iron,  &c.,  will  do  good  in  many  cases,  and  it 
is  only  the  more  severe  forms  that  are  not  cured  by  bed  and  the  means 
above  described  ;  indeed,  simple  confinement  to  bed  cures  the  majority  of 
these  children.  Should  the  prolapse  be  irreducible,  an  anaesthetic  should 
be  given  :  if  this  fails  and  there  are  no  urgent  symptoms,  a  warm  fomentation 
and  putting  the  child,  if  old  enough,  upon  his  hands  and  knees  with  the  pelvis 
raised,  will  sometimes  succeed. 

If  sloughing  occurs  the  prolapse  may  be  protected  from  irritation,  and 
dusted  over  with  boric  or  salicylic  acid,  and  kept  clean.  The  sloughing- 
will  very  likely  cure  the  prolapse,  but  it  may  be  at  the  expense  of  causing" 
a  stricture,  and  this,  if  it  is  at  the  apex  of  a  long  prolapse,  will  be  high  up 
in  the  rectum  when  the  protrusion  is  reduced. 

Failing  milder  measures,  the  actual  cautery  should  be  employed,  four  or 
five  narrow  lines  being  drawn  in  the  long  axis  of  the  gut  from  skin  margin 
to  near  the  apex. 

Paquelin's  cautery  is  the  most  useful  instrument,  and  is  better  than 
nitric  acid  or  nitrate  of  silver.  Only  the  mucous  membrane  of  the  prolapse 
should  be  burnt  through,  while  at  the  skin  margin  the  cautery  should  lay 
bare  the  sphincter  ;  sufficient  irritation  must  be  produced  to  procure  adhe- 
sions between  the  mucous  and  muscular  coats.  Bryant  advises  the  applica- 
tion of  nitrate  of  silver  over  the  whole  surface.  After  the  application  the 
bowel  should  be  reduced  and  a  pad  applied.  Another  useful  plan  is  to 
excise  wedge-shaped  strips  from  the  margins  of  the  anus,  including  a  little 
of  the  mucous  membrane,  the  base  of  the  wedge  being  at  the  anus  ;  the 
edges  of  the  wounds  are  then  brought  together,  and  the  resulting  contraction 
supports  the  bowel.  We  have  found  this  successful  in  a  very  severe  case. 
In  severe  and  irreducible  cases  the  prolapse  has  been  clamped  and  removed, 
but  this  should  only  be  done  as  a  last  resource  and  with  the  full  knowledge 
that  in  a  large  prolapse  the  peritoneum  will  probably  be  opened,  and  the 
titmost  care  must  be  taken  to  reduce  any  rectal  hernia  that  may  exist.  If  the 
peritoneum  is  wounded  it  must  be  carefully  closed  with  catgut  sutures.  This 
operation  is  rarely  justifiable  ;  we  have  once  done  it  but  unsuccessfully  :  it  is 
not  to  be  confounded  with  the  method  of  treating  prolapse  by  removal  of  strips 
of  mucous  membrane  in  the  long  axis  of  the  gut  by  means  of  the  clamp,  a 
method  sometimes  employed.' 

The  bowels  should  be  open  two  days  after  opei-ation,  as  delay  makes  the 
first  action  very  painful. 

1  Dr.  Cullingworth  related  at  the  Pathological  Society  of  Manchester,  December  1887, 
a  successful  case  of  complete  excision  of  a  large  prolapse  in  a  young  lady  in  which  the 
peritoneum  was  opened. 


Fistula  in  A  no — Condylomata — Rectal  Polypus  163 

Fistula  in  Ano  is  an  uncommon  condition  in  children,  though  we  have 
several  times  met  with  it.  As  in  adults,  it  is  apt  to  be  associated  with 
tuberculosis.  As  pointed  out  by  Mr.  Holmes,  most  of  the  fistulas  are  blind 
external  ones  ;  this  is  also  our  experience.  There  is  nothing  peculiar  in 
either  the  pathology  or  treatment,  which  is  the  same  in  children  as  in 
adults. 

We  have,  however,  introduced  the  plan  of  dividing  the  sphincter  ani 
subcutaneously  close  to  its  attachment  to  the  tip  of  the  coccyx,  and  then 
scraping  out  the  fistula.  This  is  a  less  severe  way  of  dealing  with  fistula? 
than  the  ordinary  plan,  and  is  probably  sufficient  for  all  cases  likely  to  be 
met  with  in  children. 

An  ischio-rectal  abscess  may  discharge  per  vaginam,  as  in  a  case  under 
our  care  at  the  Children's  Hospital  in  1896. 

Piles  in  children  are  usually  described  as  unknown,  or  almost  so,  and 
their  occurrence  is  no  doubt  very  rare  ;  we  have,  however,  seen  two  cases  of 
external  piles,  and  Ogston,  jun.,  has  recorded  a  case  in  a  child  3  days  old. 
In  another  instance  a  child  was  brought  to  us  for  bleeding  from  the  bowel, 
and  on  examination  a  condition  indistinguishable  from  that  of  well-developed 
internal  and  external  piles  was  found  ;  this  had  been  giving  trouble  since  the 
child  was  about  a  year  and  a  half  old,  but  the  affection  was  probably  congenital. 
Light  was  thrown  upon  the  case  by  the  presence  of  a  large  partially 
degenerated  nasvus  on  the  buttock,  quite  distinct,  and  at  a  distance  from 
the  anus,  and  probably  the  case  was  really  one  of  nsevus  of  the  anus.  The 
disease  was  readily  cured  by  applying  ligatures  just  as  for  piles.  There  was 
no  nsevoid  tissue  higher  up,  though  this  is  occasionally  met  with.  Ligature 
or  the  actual  cautery  is  the  best  treatment.  Howard  Marsh  and  Barker 
have  recorded  instances  :  in  one  the  patient,  an  adult,  ultimately  died  of 
haemorrhage. 

Condylomata  frequently  occur  in  children  about  the  anus  or  its  neigh- 
bourhood as  flat,  sessile,  pink  or  pinkish- white  elevations,  or  sometimes  as 
large  irregular  masses.  They  are  usually  a  manifestation  of  congenital  syphi- 
lis, but  sometimes,  we  believe,  simply  the  result  of  dirt  and  irritation.  When 
syphilitic  the  local  treatment  is,  of  course,  subordinate  to  the  general  measures, 
but  dusting  over  with  calomel  or  the  application  of  black  wash  usually  speedily 
cures  them.  Sometimes,  especially  if  non-syphilitic,  they  are  more  obstinate, 
and  may  require  to  be  scraped  away  or  treated  with  the  actual  cautery,  nitrate 
of  silver,  or  chromic  acid. 

Polypus  of  tlie  Rectum  is  one  of  the  diseases  which,  though  not  abso- 
lutely peculiar  to  children,  are  by  far  most  commonly  found  in  them.  Most 
cases  of  rectal  bleeding  in  children,  apart  from  that  due  to  mere  tenesmus 
and  diarrhoea,  are  due  to  polypus  ;  hence  careful  search  should  be  made  for 
a  tumour  in  all  cases  where  unaltered  blood  escapes  from  the  bowel. 

Rectal  polypi  are  usually  pedunculated  rounded  bodies  about  the  size  of  a 
hazel  nut  ;  they  are  composed  of  myxo-fibromatous  or  soft  fibro-cellular  tissue, 
or  in  some  cases  are  adenomata  ;  in  the  former  the  surface  is  smooth, 
though  sometimes  superficially  ulcerated  or  excoriated,  and  the  pedicle  is 
often  long  and  thin,  though  the  growth  in  its  early  stages  may  be  sessile. 
Adenomata  are  granular  or  warty  in  appearance.  The  anterior  wall  of  the 
rectum  about  an  inch  from  the  anus  is  the  usual  seat  of  these  growths  ;  some- 

M  2 


164  Diseases  of  the  Digestive  System 

times,  however,  they  are  attached  higher  up  in  the  bowel,  and  may  be  even 
beyond  reach  of  the  finger. 

Polypi,  besides  the  loss  of  blood,  give  rise  to  irritation  and  tenesmus, 
together  with  mucous  discharge  from  the  gut,  and  frequently  to  prolapse. 
The  growth  itself  is  often  protruded  from  the  anus  during  straining,  and  is 
sometimes  mistaken  for  prolapse  or  piles  ;  examination,  however,  readily 
enables  a  diagnosis  to  be  made,  as  the  polypus  is  quite  separate  from  the 
general  mucous  surface.  The  pedunculated  form  is  best  treated  by  simple 
twisting  off,  or  a  ligature  maybe  applied  to  the  pedicle,  which  is  then  snipped 
through  with  scissors  ;  to  do  this  conveniently  the  child  should  be  anaesthe- 
tised, and  the  rectum  well  dilated  and  a  speculum  used ;  often  during  an 
examination  the  pedicle  is  torn  through  and  the  polypus  comes  away  without 
further  trouble,  and  occasionally  the  mass  is  detached  during  defalcation  and 
passes  with  the  motion.  The  sessile  form  may  be  ligatured  or  snipped  off 
and  its  base  cauterised.     Recurrence  of  the  growth  is  improbable. 

We  have  met  with  rectal  polypus  in  two  members  of  one  family,  and 
Cripps  relates  similar  cases. 

Occasionally  the  whole  mucous  surface  of  the  lower  bowel  is  the  seat  of 
warty  adenomatous  growths,  as  in  a  remarkable  case  recorded  by  our 
colleague  Mr.  Whitehead.  Dermoid  cysts  have  also  been  found.  We  have 
had  occasion  to  remove  a  suppurating  dermoid  cyst  from  the  ischio-rectal 
fossa  of  an  adult.     Before  operation  it  was  thought  to  be  a  simple  abscess. 

Small  superficial  ulcers  and  fissures  about  the  anus  are  common  in  dirty 
and  in  syphilitic  children,  but  they  are  more  common  at  a  little  distance  from 
the  orifice  than  actually  at  the  anus.  They  give  rise  to  pruritus,  but  seldom 
to  the  se.vere  symptoms  seen  in  adults  ;  sometimes  there  is  reflex  irritation 
of  the  urinary  organs,  frequent  micturition,  &c.  In  the  non-syphilitic  cases, 
cleanliness,  the  destruction  of  worms  or  other  irritants,  and  the  application  of 
nitrate  of  silver  are  usually  sufficient.  Menthol  has  been  recommended  for 
the  pruritus.  Tuberculous  ulcers  may  be  met  with.  Ischio-rectal  abscess  is 
not  very  uncommon,  and  should  be  opened  early  •  it  is  probably  better  to 
divide  the  external  sphincter  at  the  time  to  avoid  the  risk  of  tedious  healing 
or  the  formation  of  a  fistula. 

Rectal  ulcers  are  due  to  either  follicular  inflammation,  in  which  the 
rectum  is  involved  in  common  with  the  rest  of  the  lower  gut,  or  to  rectal 
catarrh  or  the  presence  of  a  polypus.  The  symptoms  are  seldom  marked, 
and  the  condition  is  consequently  not  often  seen  ;  vide  also  Prolapse  and 
Dysentery. 

Removal  of  irritation  and  improvement  of  the  general  condition  of  the 
intestinal  mucous  membrane  are  the  only  treatment  required. 


i6- 


CHAPTER    IX 

DISEASES    OF    THE    DIGESTIVE    SYSTEM — {contifllied) 

Malformations  and  Deformities  of  the  Dig'estive  System 

Bare-lip. — The  upper  lip  is  developed  from  the  fr.onto-nasal  process  and 
the  maxillary  processes  which  in  the  normal  course  of  development  fuse  in 
front  of  the  mandibular  fissure.     Should  this  fusion  fail  to  take  place  on 


Fig.  22. — Shows  the  lines  of  union  of  the  face,  and  indicates  the  origin  of  the  chief  malforma- 
tions. AF,  af',  situations  of  congenital  auricular  fistula;.  I.,  II.,  III.,  IV.,  indicate  the 
external  orifices  of  branchial  fistula;.  I.  is  the  e.\-ternal  auditory  meatus  ;  of,  the  orbital 
fissure  ;  mf,  the  mandibular  fissure  ;  hh',  the  lines  of  lateral  hare-lip  ;  CF,  cf',  mark  the 
situations  of  congenital  aw/crt/ fistulsE.     (From  Bland  Sutton,  Lancet,  Feb.  i,  iS88.) 

either  or  both  sides,  a  single  or  double  hare-lip  respectively  results.  If 
the  inward  growth  of  the  palatine  processes  which  should  take  place  to 
separate  the  nasal  and  buccal  cavities  fails,  cleft  palate  occurs. 


1 66 


Diseases  of  the  Digestive  System 


The  priemaxillse  are  formed  from  the  globular  processes  forming  the 
angles  of  the  fronto-nasal  process ;  hence,  should  the  lateral  process  not  fuse 
\\ith  the  globular,  a  cleft  between  the  priemaxilla  and  the  maxilla  will 
result  on  that  size,  while,  if  there  is  suppression  of  the  two  globular  pro- 
cesses and  septum,  median  hare-lip  follows  ;  this,  though  exceedingly  rare  in 
man,  is  met  with  more  or  less  constantly  in  some  mammals  in  which  the 
globular  processes  fail  to  unite  with  one  another.  ^ 

As  to  the  actual  causes  of  such  arrest  of  development  much  controversy 
exists.  It  is  commonly  asserted  that  frights  and  shocks  of  various  kinds,  as 
well  as  strong  maternal  impressions  of  other  sorts  occurring  about  the 
time  of  the  development  of  these  parts,  may  determine  the  arrest  of  growth 
which  results  in  such  malformations.  Although  many  instances  have  been 
brought  forward  to  show  a  causal  relation  between  the  two  facts,  it  is  not 
clearly  established  that  anything  more  than  a  coincidence  really  exists. 

It  is,  however,  certain  that  in  many  cases  there  is  an  hereditary  tendency 
to  such  defects,  and  it  is  also  certain  that  they  are  often  associated  with  other 

congenital  malformations.     It  is  asserted 

that  the  hereditary  tendency  is  commonly 
transmitted  on  the  father's  side. 

Various  degrees  of  hare-lip  are  found  ; 
Mr.  Lucas  believes  that  congenital  absence 
of  an  upper  lateral  incisor  is  sometimes 
the  forerunner  of  hare-lip  and  cleft  palate 
in  a  later  generation  ;  in  some  instances 
there  is  merely  a  deficiency  of  the  mus- 
cular fibres  of  the  orbicularis,  so  that 
although  the  lip  is  not  actually  fissured 
there  is  a  furrow  from  the  absence  of 
muscle  and  the  consequent  thinning  of  the 
lip  which  at  the  affected  part  consists  only 
of  skin  and  mucous  membrane,  often  some- 
what imperfect  in  structure,  together  with 
an  intervening  layer  of  connective  tissue. 
In  other  cases  there  is  a  shallow  notch 
in  the  prolabium  or  at  the  anterior  nasal 
orifice,  the  parts  being  otherwise  well 
formed.  Between  these  conditions  and 
the  most  severe  forms  of  hare-lip  all  degrees  of  deformity  may  exist  (figs. 
23  and  24). 

As  the  superficial  structures  are  developed  more  or  less  independently  of 
the  bony  framework  of  the  face,  hare-lip  may  occur  without  any  cleft  of  the 
palate,  and  without  any  separation  of  the  praemaxillafrom  the  maxilla.  Most 
commonly,  however,  if  the  hare-lip  is  complete,  i.e.  if  it  extends  into  the 
nostril  on  one  or  both  sides,  there  is  also  deformity  of  the  bones,  either  non- 
union of  the  prcemaxilla  or  single  or  double  cleft  palate.  Thus  there  may 
be  a  mere  notch  in  the  line  of  the  gum,  a  cleft  through  the  alveolar  margin 
on  one  side,  a  cleft  running  backwards,  on  one  side  of  the  nasal  septum 
through  the  hard  and  soft  palates,  or  a  double  cleft  isolating  the  pr^emaxilla 
i    Vide  Bland  Sutton,  Lancet,  P'ebruary  18,  1888. 


Fig.  23. — A  simple  case  of  Double  incom- 
plete Hare-lip.  This  is  much  rarer  than 
the  complete  variety. 


Hair-lip 


167 


from  the  maxilla;  and  leaving  it  protruding  from  the  end  of  the  nasal  septum 
while  the  two  halves  of  the  hard  and  soft  palate  are  completely  separated  and 
the  nasal  septum  is  seen  in  the  middle  line  as  a  prominent  ridge  not  attached 
to  either  side  of  the  palate — complete  or  double-cleft  palate — the  septum  is 
often  seen  to  taper  off  and  end  as  a  ridge  upon  the  upper  wall  of  the  pharynx. 
It  is  usually  said  that  cleft  palate  is  always  single,  but  the  term  may  well  be 
limited  to  those  cases  where  the  septum  is  attached  to  one  palate  process 
only.  In  other  instances  the  failure  of  union  may  occur  only  in  the  soft 
palate,  more  often  in  the  soft  with  just  the  posterior  edge  of  the  hard  palate, 
or  in  slighter  degrees  of  the  deformity  still  the  uvula  alone  may  be  bifid,  or 
the  palate  perforated.  Most  rare  of  all  is  cleft  of  the  hard  without  cleft  of 
the  soft  palate.  We  have  once  or  twice  seen  this  condition,  which  is  apt  to 
be  mistaken  for  a  congenital  syphilitic  or  other  lesion.  In  some  recorded 
cases  the  uvula  has  been  absent. 

Two  other  conditions  associated  with  hare-lip  and  cleft  palate  respectively 
are  of  extreme  importance  as  regards  successful  operation  ;  the  one  is  the 
flat,  wide,  distorted  ala  of 
the  nose  found  in  complete 
hare-lip  ;  the  other  is  the 
pitch  of  the  palate  arch, 
which  may  be  either  wide 
and  flat  or  very  high  and 
narrow  ;  the  latter  condi- 
tion is  said  to  be  often 
associated  with  mental 
deficiency. 

Sometimes  the  pr^e- 
maxilla  carries  the  four 
incisor  teeth,  and  these 
are  therefore  implanted  in 
the  projecting  mass  in 
cases  of  "complete  double 
hare-lip.  In  some  in- 
stances, however,  one  in- 
cisor tooth  is  attached  to  the  maxilla,  most  commonly  the  outer  tooth  is 
suppressed  altogether,  its  sac  having  apparently  been  lost  in  the  cleft. 

Rotation  of  PrcBmaxilla. — Very  frequently  there  is  some  rotation  of 
the  prsemaxilla  upon  a  vertical  axis,  especially  in  unilateral  cleft  ;  in  such 
cases  the  teeth  are  also  rotated  and  may  be  so  directed  that  the  outer  border, 
or  in  some  instances  the  cutting  edge,  looks  directly  forwards.  This  position 
of  the  teeth  requires  to  be  remedied  after  their  complete  eruption.  As,  how- 
ever, hare-lip  is  now  usually  operated  upon  before  the  teeth  are  cut,  their 
exact  position  is  in  such  cases  of  little  importance  at  the  time. 

Feeble  Vitality. — The  deformity  of  simple  hare-lip  unaccompanied  by 
malformation  of  the  palate  is  important  almost  solely  on  account  of  the 
disfigurement,  though  it  must  be  borne  in  mind  that  many  of  these  children 
have  other  deformities  or  are  weakly,  and,  though  without  any  actual  malforma- 
tion, do  not  seem  to  have  sufficient  vitality  to  make  it  possible  to  rear  them. 

When,  however,  the  failure  of  the  union  affects  the  palate  as  well  as  the  lip. 


Fig 


24. — Severe  Double  Hare-lip.     Showing  the  projecting 
praemaxilla. 


1 68  Diseases  of  the  Digestive  System 

other  ill  results  follow ;  the  child  is  unable  to  suck  from  inability  to  produce 
a  vacuum  in  the  mouth  ;  its  nasal  passages  and  pharynx  are  exposed  to  the 
air  and  become  affected  with  chronic  catarrh,  its  tongue  is  dry  and  the  air 
entering  its  lungs  is  imperfectly  warmed.  Even  when  fed  with  a  spoon  the 
food  often  regurgitates  through  the  nose.  Hence  to  the  already  weakly  con- 
dition of  the  child  are  added  the  dangers  of  insufficient  nutrition  and  catarrh 
of  the  respiratory  tract.  It  is  not,  therefore,  to  be  wondered  at  that  only  a 
small  proportion  of  children  so  affected  survive  ;  should  they  do  so,  they  are 
subject  to  the  further  drawback  of  imperfect  and  indistinct  speech.  It  is 
alleged  that  many  of  these  children  die  from  starvation,  which  might  be 
prevented  by  operation  ;  we  do  not  think  this  is  true  ;  we  believe  they  would 
die  in  any  case  from  simple  lack  of  vitality. 

In  those  cases  where  the  child  is  unable  to  suck,  it  should  be  fed  in  an 
upright  posture,  when  the  milk  is  less  likely  to  regurgitate  through  the  nose, 
or  one  of  the  special  obturator  teats  devised  by  Mr.  Mason  and  others  em- 
ployed ;  probably  the  best  of  these  is  Oakley  Coles'  rubber  teat. 

The  treaimeiit  of  hare-lip  is  necessarily  purely  operative  ;  several  impor- 
tant questions  have,  however,  to  be  considered  in  each  individual  case.  First, 
it  is  clearly  of  no  use  to  operate  on  an  infant  that  is  incapable  of  living  from 
the  presence  of  some  other  deformity  incompatible  with  life,  nor  in  cases 
where  the  general  health  of  the  child  is  feeble  and  it  is  losing  weight,  since 
union  of  the  wound  would  not  take  place.  No  operation  then  should  be  done 
unless  the  child  is  in  perfect  health,  and  the  time  of  actually  cutting  a  tooth 
should  be  avoided. 

Age  for  operation. — Next  comes  the  question  ofthe  best  age  for  operation. 
On  the  one  hand  it  must  be  borne  in  mind  that  there  is  a  certain  amount  of 
risk  attending  the  necessary  loss  of  blood  and  the  shock  in  a  very  young'  infant, 
and  on  the  other  hand  that,  if  the  deformity  is  severe,  the  effect  of  closing 
the  cleft  in  the  lip  as  regards  moulding  the  subjacent  parts  into  their  natural 
shape  will  be  greater  the  younger  the  child  and  the  softer  the  tissues.  As  has 
been  well  shown  by  Dr.  Rawdon,  of  Liverpool,  and  others,  a  most  remarkable 
modelling  process  in  the  outline  of  the  upper  jaw  takes  place  after  closure  of 
a  hare-lip,  and  more  than  this,  the  width  of  the  cleft  in  a  divided  palate  is 
much  reduced  after  a  time  by  uniting  the  lip. 

Increased  facility  in  feeding  and  the  removal  of  a  hideous  deformity  are 
other  reasons  for  early  interference,  while  experience  shows  that  early  opera- 
tion is  not  attended  with  a  specially  high  rate  of  mortality.  Many  infants  die 
shortly  after  the  operation  for  hare-lip,  but  in  most  of  these  death  is  due  to 
malnutrition,  not  to  the  operation. 

The  common  practice  now  is  to  operate  at  any  time  after  the  first  three 
weeks  of  life  in  the  less  severe  cases  and  a  month  or  two  later  in  the  more 
serious  deformities,  double  hare-lip  being  dealt  with  later  still  ;  operations 
are,  however,  often  successfully  done  within  the  first  few  days  of  life.  Our 
own  preference  is  not  to  operate  before  a  month  in  single  hare-lip,  nor  before 
six  months  in  severe  deformity. 

Operation.— \\.  is,  in  our  opinion,  much  better  in  all  cases  to  give  chloro- 
form for  the  operation.  The  coronary  arteries  should  then  be  controlled  by 
bulldog  forceps  or  finger  pressure,  and  the  lip  very  freely  detached  from  the 
maxilla,  the  dissection  being  carried  far  outwards  along  the  jaw,  upwards 


,  Hare-lip  1 69 

nearly  to  the  lower  margin  of  the  orbit,  and  inwards  and  upwards  so  as  to 
freely  detach  the  alas  nasi  from  the  subjacent  bone. 

The  extent  of  the  separation  will,  of  course,  depend  u]jon  the  severity  of 
the  case  ;  but,  as  a  rule,  failure  is  more  often  due  to  insufficient  separation 
than  to  any  other  single  cause. 

The  bleeding  during  this  part  of  the  operation  is  often  free,  but  is  easily 
controlled  by  pressure,  and  stops  immediately  after  the  stitches  are  put  in  ; 
for  this  reason  we  sometimes  pare  the  edges  of  the  cleft  before  freeing  the 
lip,  though  if  the  paring  is  done  last  it  is  easier  to  adjust  the  edges  exactly. 
It  is  very  important  to  slice  away  the  sides  of  the  cleft  freely,  and  not  merely 
to  scrape  them  or  to  take  away  a  thin  shaving  ;  too  little  is  much  more  often 
taken  away  than  too  much. 

In  adjusting  the  edges  of  the  wound,  the  chief  points  to  attend  to  are  that 
the  prolabial  margin  on  one  side  exactly  corresponds  with  that  on  the  other  ; 
secondly,  that  the  highest  suture  is  well  within  the  nostril,  so  as  to  prevent  a 
gap  at  the  upper  margin,  and  to  remedy  the  tendency  to  flattening  of  the 
nostril  ;  thirdly,  to  insert  a  suture  on  the  inner  and  under  (mucous)  surface 
of  the  lip  ;  this  more  than  anything  else  prevents  the  appearance  of  an  un- 
sightly notch  at  the  lower  end  of  the  line  of  union.  The  main  sutures  should 
be  made  to  include  the  whole  thickness  of  the  lip  except  the  mucous  mem- 
brane ;  the  intermediate  ones  may  be  only  superficial. 

Silver  wire  sutures,  usually  about  three  in  number,  with  intervening  horse- 
hair stitches,  will  be  found  very  successful,  and  are,  we  think,  on  the  whole, 
the  best. 

Hare-lip  pins  are  hardly  ever  necessary,  and  should  not  be  used  if  it  is 
possible  to  avoid  it.  We  have  not  used  them  for  years.  If  the  lip  is  freely 
separated  from  the  upper  jaw,  there  will  be  no  tension.  We  used  sometimes 
to  put  pins  in  temporarily  to  keep  the  parts  in  apposition  while  the  rest  of  the 
stitches  are  being  inserted,  and  then  remove  them  at  the  end  of  the  opera- 
tion. If  the  pins  are  left  in,  it  should  be  for  not  longer  than  forty-eight  hours  ; 
the  rest  of  the  stitches  may  be  taken  out  a  day  or  so  later,  according  to  the 
amount  of  Irritation  set  up  and  the  condition  of  the  child.  Where  the  power 
of  repair  is  feeble,  the  sutures  should  be  left  in  longer.  Some  surgeons  pre- 
fer silk  or  gut  sutures.  The  first  stitch,  if  pins  are  not  used,  should  be  put 
in  opposite  the  prolabial  margin  ;  this  answers  the  double  purpose  of  con- 
trolling the  coronary  arteries  and  of  fixing  the  level  of  adjustment  of  the  two 
sides.  If  forceps  have  been  used  for  controlling  the  bleeding,  they  should  be 
removed  just  before  putting  in  the  stitches. 

Some  surgeons  apply  a  strip  of  strapping  over  the  lip  after  the  operation, 
or  use  a  Hainsby's  truss  ;  neither  is  necessary.  We  prefer  to  dust  the  wound 
over  with  boric  powder  and  leave  it  exposed.  The  strapping  is  objectionable 
in  that  it  tends  to  collect  blood  and  mucous  discharge  from  the  nostril,  and 
so  to  irritate  the  wound.  It  is.  however,  sometimes  wise  to  put  plaster  on 
for  forty-eight  hours  after  removing  the  sutures  until  the  union  is  quite  firm, 
and  it  is  a  good  plan  to  lay  a  narrow  strip  of  lint  over  the  line  of  union 
beneath  the  plaster. 

If  the  child  has  not  been  weaned  before  the  operation,  it  should  be 
allowed  to  suck  as  soon  as  it  recovers  from  the  chloroform  ;  in  such  case 
care  must  be  taken  to  prevent   injury  to  the  mother's  breast  from  the  wire 


170  Diseases  of  the  Digestive  System 

sutures.  In  most  cases,  however,  the  child  has  been  bottle  or  spoon 
fed. 

In  any  case  the  hands  must  be  carefully  secured  by  bandaging  them  to  the 
chest  with  a  flannel  bandage  or  by  some  similar  means,  and  watch  kept  that 
no  injury  is  done  to  the  lip. 

The  principal  methods  of  operating  for  single  hare-lip  are  as  follow  : 
each  case  must  be  managed  according  to  its  special  needs,  no  one  method 
answering  in  all  cases  : 

1.  The  edges  of  the  fissure  are  simply  pared  by  a  straight  incision  and 
brought  together.  This,  though  answering  well  in  some  cases,  is  apt  to  leave 
a  notch  at  the  prolabial  margin  unless  there  is  abundance  of  material  to  work 
with.  By  making  the  line  of  incision  slightly  curved,  with  the  concavity 
towards  the  cleft,  the  notching  may  often  be  avoided  (fig.  25  e,f). 

2.  The  single  flap  method  shown  in  fig.  25  (^,  d)  is  often  useful. 


/ ^ 3 


Fig.  25.- -Diagrams  slightly  altered  from  Lane  ('Operative  Surgery')  to  show  the  modes  of 
refreshing  and  uniting  the  edges  in  single  hare-lip.  In  a,  b,  the  angular  incision  allows  two 
flaps  to  be  turned  downwards.  In  c,  d,  a  single  flap  from  the  left  side  is  fixed  to  the  opposite 
side,  as  in  Owen's  operation.  The  flap  should  be  much  longer  than  that  shown  in  the  figure. 
In  0,^,  the  edges  are  pared,  making  the  lines  of  incision  strongly  concwiie  inwards,  g  shows 
Golding-Bird's  'rectangular  operation  '  (vide  Brit.  Med.  Journ.  October  1890). 

3.  Malgaigne's  operation  of  turning  down  two  opposed  flaps  may  be  em- 
ployed ;  it  is  chiefly  useful  for  cases  where  a  notch  remains  after  previous 
operation  ((2,  U). 

4.  Perhaps  the  most  generally  applicable  methods  are  those  shown  in 
fig.  25  {c-d.,  ef). 

5.  The  more  complicated  operations  of  Giraldes  and  Collis  are  seldom 
employed,  but  it  is  occasionally  very  useful  to  carry  the  incision  round  the 
ala  of  the  nose  in  severe  cases  ;  by  this  means  the  depth  of  the  lip  can  be 
greatly  increased  ;  this  plan  was,  we  believe,  first  employed  by  Dr.  Ra\\don, 
of  Liverpool.     Many  other  methods  are  described.     Owen's  is  very  good. 

In  double  hare-lip  two  special  difficulties  have  to  be  met,  the  management 
of  the  praelabium  and  of  the  prasmaxilla.     The  praslabium  may  be — 

I.  Pared  at  its  sides  and  free  extremity  so  as  to  make  a  semicircular  or 
tongue-shaped  flap  which  is  fitted  between  the  upper  parts  of  the  two  lateral 
flaps,  these  having  been  previously  pared. 


Hare-lip — Cleft  Palate  I7i 

2.  If  long  enough,  the  prEchibium  may  l)e  brought  down  to  make  the 
central  part  of  the  lip,  being  pared  only  at  its  sides,  and  the  lateral  flaps  are 
then  fitted  to  it  instead  of  to  each  other. 

3.  The  central  flap  may  be  removed  altogether,  and  the  two  sides  brought 
together  throughout  their  whole  length. 

4.  The  pra^labium,  having  been  dissected  away  from  the  prasmaxilla,  may 
be  doubled  upon  its  base  and  turned  up  to  form  a  columna  for  the  nose. 
The  first  and  second  of  these  plans  are  the  most  generally  useful. 

The  prtemaxilla  in  some  cases  may  be  pushed  gradually  backwards  by 
constant  pressure  with  a  pad  before  the  hare-lip  is  operated  on,  or  it  may  be 
forcibly  pushed  back  at  once  ;  this  is  open  to  the  objection  pointed  out  by 
F.  Mason,  that  the  wedging  back  of  the  prasmaxilla  may  tend  to  keep  open 
the  cleft  in  the  palate.  Removal  of  a  wedge-shaped  piece  from  the  septum 
nasi  or  of  lateral  pieces  from  the  prsemaxilla  is  a  plan  sometimes  adopted. 
The  method  we  prefer  where  the  prsemaxilla  cannot  be  covered  is  to  shell 
out  the  bone,  leaving  the  muco-periosteum  to  preserve  the  outline  of  the  hp, 
and  then  bring  the  lip  together  ;  '  this,  we  think,  is  certainly  better  than  entire 
removal  of  the  prtemaxilla,  which  produces  flattening  of  the  lip.  Where  the 
praemaxilla  is  turned  upon  a  vertical  axis  so  that  one  edge  looks  forwards  it 
may  be  forcibly  rotated  into  position,  but  if  the  lip  can  be  united  over  the 
projection  the  prominence  will,  as  already  pointed  out,  soon  diminish. 

Any  notch  left  at  the  free  margin  of  the  lip  or  at  the  nostril  can  usually 
be  closed  by  a  subsequent  operation.  Should  primary  union  fail  throughout 
an  attempt  should  be  made  at  once  to  procure  secondary  adhesion  by  either 
putting  in  fresh  sutures,  or,  if  the  tissues  are  too  soft  and  inflamed  to  hold 
them,  by  applying  strapping  to  bring  the  sides  together.  If  the  child's 
health  is  good,  this  will  probably  succeed  ;  failure  is,  however,  often  due  to 
malnutrition  ;  in  such  cases  union  cannot  be  expected  to  occur,  and  a  second 
attempt  should  be  put  off  until  the  health  is  improved.  It  is  wiser  not  to 
operate  too  soon  a  second  time  ;  many  cases  that  look  unsatisfactory  after 
operation  improve  much  in  time.  Our  former  house  surgeon  and  old  friend 
Mr.  Murray  of  Liverpool,  while  bringing  a  flap  across  very  much  as  in 
Owen's  method,  uses  a  button  suture  to  bring  up  the  ala  nasi  and  avoid  the 
flattening  of  the  nostril,  which  is  sometimes  difficult  to  obviate. 

The  particular  mode  of  operating  must  be  selected  for  each  individual 
case,  looking  especially  to  the  size  of  the  central  portion  of  the  lip  in  double 
hare-lip  and  to  the  inequality  of  the  two  sides  in  the  single  deformity. 

Cleft  Palate. — The  varieties  of  cleft  palate  have  already  been  mentioned. 
The  severer  forms  are  commonly  associated  with  double  hare-lip — indeed,  it 
is  said  to  be  very  rare  for  double  hare-lip  to  occur  without  cleft  palate,  and  no 
doubt  this  is  true  in  the  complete  forms  of  hare-lip. 

Here  a  brief  account  of  the  modes  of  treating  the  deformity  can  alone  be 
given. 

For  choice  the  operation  should  be  performed  between  the  fourth  and 
sixth  years,  but  in  the  less  severe  cases  it  may  be  done  as  early  as  the  third 
year ;  before  this  it  is  not  wise  to  attempt  it,^  unless  in  exceptional  circum- 

1  This  method  was  introduced  by  Sir  W.  Fergusson. 

"^  Mr.  Cluttoii  has  operated  successfully  in  two  favourable  cases  of  cleft  of  the  soft 
palate  at  12  months  old.     Lancet,  June  6,  1887. 


1/2  Diseases  of  tJie  Digestive  System 

stances,  since  the  risk  both  of  failure  of  the  operation  and  of  the  child's 
life  is  much  greater,  though  some  surgeons  advocate  operation  in  the  second 
or  even  the  first  year.  Thus  Mr.  Murray  emphasises  the  opinion  that  the  cleft 
should  be  closed  before  the  child  has  learned  to  talk,  so  that  it  may  not  have 
to  overcome  the  defects  of  speech  which  it  has  acquired  if  the  operation  is 
postponed.  He  therefore  closes  the  lip  in  complete  cases  at  about  the  fourth 
week,  the  soft  palate  at  the  end  of  the  first  year,  and  the  hard  palate  later. 
We  have  operated  also  earlier  than  the  time  we  have  advocated  in  slight 
cases,  but  are  not  inclined  to  attempt  closure  of  a  severe  case  of  cleft  of  both 
hard  and  soft  palate  earlier  than  the  third  year  at  soonest.  As  in  all  plastic 
operations,  care  must  be  taken  that  the  child  is  in  good  health.  The  other 
general  rules  to  be  observed  are  :  the  edges  of  the  cleft  must  be  freely  pared, 
all  tension  must  be  carefully  avoided,  the  muco-periosteum  must  be  thoroughly 
loosened  at  the  junction  of  the  hard  and  soft  palates  in  cases  of  cleft  of  the 
velum  alone,  no  hard  food  must  be  given  till  union  is  complete,  and  if  the 
operation  is  only  partially  successful  or  fails  altogether,  another  attempt 
should  be  made  at  the  end  of  three  months. 

Staphylo7'-aphy,  or  the  operation  for  closure  of  a  cleft  of  the  soft  palate, 
consists  in  freely  paring  the  edges  of  the  cleft  throughout,  then  a  sufficient 
number  of  sutures  are  passed,  and  next  the  attachment  of  the  soft  palate  to 
the  hard  is  carefully  loosened,  and  finally,  the  palate  muscles  having  been 
divided  to  relieve  tension,  the  sutures  are  tightened  up.  The  exact  mode  of 
operating  that  we  prefer  is  as  follows.  The  child  is  anaesthetised,  a  pillow 
is  placed  beneath  the  shoulders,  and  the  head  allowed  to  fall  right  back  so 
that  the  roof  of  the  pharynx  is  almost  horizontal  ;  in  this  position  light 
enters  the  mouth  well,  and  the  blood  and  saliva  collect  in  a  pool  in  the 
pharynx  instead  of  irritating  the  larynx.  A  gag  is  then  inserted,  the  whole 
of  the  cleft  carefully  pared,  and  then  from  four  to  seven  wire  sutures  are  put 
in  in  the  following  way  :  a  slightly  curved  needle  in  a  handle  is  passed 
through  the  edge  on  one  side  into  the  cleft,  it  is  then  threaded  with  wire  and 
withdrawn,  the  wire  is  disengaged,  the  needle  passed  similarly  through  the 
other  side  and  threaded  with  the  end  already  passed  ;  this  is  then  drawn 
through  the  second  side  by  removing  the  needle,  bringing  the  wire  across 
the  gap  with  the  two  ends  projecting  on  the  oral  sui'face.'  For  the  uvula  we 
often  use  horsehair  sutures.  When  all  the  sutures  are  passed  an  incision  is 
made  through  the  mwco-periosteum  of  the  hard  palate  down  to  the  bone  on 
each  side  of  the  front  of  the  cleft  and  well  awayfrom  it,  the  muco-periosteum 
is  then  carefully  detached  from  the  bone  all  round  the  anterior  extremity  of 
the  cleft  so  that  the  soft  parts  are  quite  free  and  loose.  Next,  holding  all 
the  sutures  together  in  the  left  hand,  the  palate  knife  is  carried  backwards 
and  outwards  from  the  incision  already  made  until  the  levator  and  tensor 
palati  are  freely  divided  and  the  velum  is  quite  lax.  Sometimes  it  is  well 
to  divide  the  palato-giossus  and  pharyngeus  by  snipping  through  the  pillars 
of  the  fauces.  If  there  is  no  tension  it  is  a  good  plan  to  make  the  relaxation 
incisions  after  twisting  up  the  wires.  A  minute  or  two  is  then  given  up  to  firm 
pressure  with  a  sponge  upon  the  palate,  so  that  all  bleeding  may  be  stopped. 
Finally,  the  wires  are  twisted  up  :  we  usually  begin  with  the  middle  wires, 

1  For  knowledge  of  this  most  simple  plan  we  are  indebted  to  our  colleague,  Mr. 
Hardie. 


Cleft  Palate  173 

as  they  bear  tension  best.  The  ends  are  then  cut  short,  the  cleft  inspected 
to  see  that  the  Hps  are  accurately  adjusted,  and  that  there  is  no  tension,  and 
the  gag  is  then  removed.  We  usually  free  the  muco-periosteum  from  the 
bone  before  passing  the  sutures. 

Various  modifications  of  the  opei'ation  are  of  course  well  known,  and  will 
be  found  described  in  the  general  text-books. 

During  the  operation  it  is  important  to  avoid  the  use  of  sponges  as  long 
as  possible,  since  mopping  out  the  pharynx  much  increases  the  amount  of 
secretion  poured  out. 

The  after  treatment. — The  hands  must  be  carefully  secured  to  avoid 
injury  to  the  palate,  and  no  solid  food  should  be  given  for  a  week.  Many- 
surgeons  give  nothing  by  mouth  at  all  for  forty-eight  hours,  and  feed  the 
patient  by  enemata.  Others  allow  milk  from  the  first,  and  sops  after  two  or 
three  days  ;  othei^s,  again,  allow  soft  solids  from  the  first  ;  probably  it  is  better 
to  restrict  the  diet  to  milk  for  two  or  three  days  and  then  allow  soup  and 
sops  till  the  end  of  the  week  ;  after  this  the  ordinary  diet  may  be  gradually 
resumed,  avoiding  of  course  any  hard  or  irritating  material.  The  stitches 
we  usually  leave  to  take  care  of  themselves,  and  nothing  more  is  seen 
of  them  ;  the  child  probably  spits  them  out.  If,  however,  they  are  setting  up 
irritation,  or  if  after  a  few  weeks  they  have  not  come  away,  they  should  be 
removed.  Any  little  granulating  point  or  small  perforation  left  at  the  anterior 
extremity  of  the  cleft  will  usually  heal  up  of  itself ;  if  it  does  not  do  so  the 
application  of  nitrate  of  silver  will  sometimes  succeed,  or  in  other  cases  a 
second  little  operation  may  be  required. 

Only  one  mode  of  performing  the  operation  of  Uranoplasty.^  or  closure 
of  a  cleft  of  the  hard  palate,  will  be  described  here  ;  in  our  experience  it  is 
much  more  successful  than  the  other  plans,  and  if  it  fails  there  is  less  difficulty 
in  a  second  operation  than  after  the  so-called  osteoplastic  method. 

Operation  by  ninco-periosteal  flaps  consists  in  paring  the  edges  of  the 
cleft  throughout,  then  an  incision  is  made  midway  between  the  alveolar  margin 
of  the  palate  and  the  cleft  for  its  whole  length  down  to  the  bone.  The  bridge 
of  muco-periosteum  between  the  incision  and  the  cleft  is  then  stripped  off 
the  bone  with  a  blunt  raspatory  completely  into  the  cleft  throughout  its 
whole  length  ;  this  must  be  done  most  thoroughlj^,  so  that  there  is  no  tension 
upon  the  flaps,  which,  however,  must  not  be  bruised  more  than  can  possibly 
be  helped.  The  sutures  are  then  passed  as  in  the  operation  upon  the  soft 
palate  and  twisted  up. 

In  case  of  operation  upon  the  soft  palate  alone  we  prefer  the  plan  of 
paring  the  edges  first,  then  passing  the  sutures,  and  then  dividing  the  muscles 
before  twisting  the  sutures  ;  while  in  uranoplasty  the  edges  are  first  pared, 
then  the  flaps  raised,  and  lastly  the  sutures  are  passed  and  twisted  up. 

In  quite  young  children  it  is  an  advantage,  if  there  is  a  complete  cleft  of 
both  hard  and  soft  palates,  to  close  the  soft  palate  alone  first  and  some  months 
after  to  close  the  hard  ;  the  union  of  the  velum  tends  to  draw  together  the 
sides  of  the  hard  palate  during  growth  and  make  subsequent  closure  of  the 
cleft  more  easy.  Operation  on  a  complete  cleft  of  both  hard  and  soft  palates 
should  be  reserved  for  older  children,  who  can  better  bear  the  increased 
severity  of  the  more  extensive  operation.  We  usually  do  the  whole  operation 
at  once. 


174  Diseases  of  the  Digestive  System 

The  shape  of  the  palate  arch,  already  alluded  to,  is  of  importance  ;  the 
higher  and  narrower  the  arch  the  easier  in  most  cases  is  the  closure  of  the 
cleft,  since  there  is  proportionately  more  tissue  to  draw  across  the  gap. 

In  some  children  the  cleft  is  so  wide,  that  is,  the  failure  of  growth  of 
the  palate  processes  is  so  marked,  that  it  is  impossible  to  close  the  opening 
by  a  plastic  operation  ;  in  such  cases  an  obturator  should  be  fitted  to  the 
gap.     Operation  is,  however,  nearly  always  practicable. 

In  some  instances  the  deficiency  may  be  lessened  by  operation,  even 
though  complete  closure  is  impossible  ;  a  smaller  obturator  is  then  sufficient. 

Obturators  are  liable  to  increase  the  size  of  the  opening  by  pressure 
unless  carefully  managed.^ 

The  results  of  the  operation  are,  in  successful  cases,  that  the  power  of 
swallowing  is  improved,  the  food  no  longer  tending  to  pass  into  the  nasal 
fossae,  and  the  tendency  to  pharyngeal  catarrh  is  lessened.  The  voice  is  not 
improved  by  the  operation  itself,  but  closure  of  the  cleft  renders  it  possible 
by  subsequent  training  to  greatly  improve  speech  ;  and  if  sufficient  care  is 
taken  it  may  be  rendered  practically  perfect ;  this  no  training  can  do  while 
the  cleft  remains. 

Mr.  Mason's  plan  of  completely  dividing  the  soft  palate  backwards  is 
devised  to  remedy  the  rigidity  of  the  velum,  sometimes  resulting  after  opera- 
tion, which  interferes  with  speech  and  deglutition. 

A  high-pitched  roof  to  the  mouth  sometimes  produces  exactly  the  same 
effect  upon  speech  as  a  cleft  palate  ;  this  has  been  treated  by  Mr.  Warrington 
Haward  by  loosening  the  muco-periosteum  and  excising  a  strip  :  the  edges 
of  the  wound  are  then  brought  together  so  as  to  lower  the  pitch  of  the  arch. 
Much  improvement  followed  in  his  case.'^ 

Otber  IVXalformations. — The  rarer  forms  of  congenital  malformation 
of  the  lips  require  little  more  than  mention  here. 

A  median  fissure  of  the  upper  lip  is  of  extreme  rarity,  but  does  occur  ; 
it  results  from  complete  suppression  of  the  lower  part  of  the  preefrontal 
process.^  Mr.  Reginald  Smith  of  Warrington  informs  us  that  he  met  with 
such  a  case  in  the  summer  of  1898. 

Cleft  of  the  lower  lip  has  occasionally  been  met  with,  as  well  as  a 
peculiar  mammillary  projection  on  each  side  of  the  middle  line.  In  one 
instance  the  cleft  ran  downwards  from  the  angle  of  the  mouth.  Murray  is 
quoted  by  Mason  as  having  seen  a  case  where  congenital  sacculi  existed  in 
the  lower  lip  in  four  members  of  one  family.  A  similar  case  is  recorded  by 
Sympson  in  the  '  Brit.  Med.  Jour.'  December  9,  1882.  We  have  also  seen 
more  than  one  of  these  cases. 

Macrostoma,  or  congenital  enlargement  of  the  mouth,  is  usually  uni- 
lateral, occurs  most  commonly  in  females,  and  is  not  hereditary  ;  it  may  be 
associated  with  branchial  fistulse  and  supernumerary  auricles  together  with 
hare-lip,  as  in  a  case  of  our  own.  In  Guersant's  case,  figured  by  Mason  in 
'  Surgery  of  the  Face,'  the  deformity  was  bilateral  and  clearly  due  to  failure 
of  union  of  the  superior  maxillary  with  the  fronto-nasal  and  external  nasal 

1  Coles'  modification  of  Suersen's  is  probably  the  best  obturator.  Vide  Brit.  Med. 
Jour.  November  4,  1882.  ^  Lancet,  January  15,  1887. 

2  For  a  discussion  on  this  subject,  see  Mr.  Bland  Sutton's  admirable  lectures,  Lancet, 
February  18,  1888,  and  Tumours,  Innocent  and  Malignant ,  1893. 


Macrostoma — Macrocheilia — Microstoma 


175 


Fig.  26. — Macrostoma  on  the  left  side,  with  a  faint 
scar-like  mark  leading  up  towards  a  depression  at 
the  base  of  a  well-marked  supernuraerarj'  auricle. 
(Mr.  Southam's  case.)     See  p.  174. 


processes,  i.e.  persistence  of  the  lachrymal  fissure.'  In  the  more  usual  form 
it  is  a  persistence  merely  of  the  great  buccal  aperture  from  incomplete  fusion 
of  the  superior  and  inferior 
maxillary  plates,  i.e.  of  the 
maxillary  process  of  the 
pterygo-palatine  arch  and 
the  lower  part  of  the  man- 
dibular arch  from  which 
Meckel's  cartilage  and  the 
lower  jaw  arise.  The  con- 
dition is  easily  remedied  by 
paring  and  uniting  the  edges 
of  the  fissure  to  the  required 
extent. 

Macrocheilia,  or  en- 
largement of  the  lips,  is 
occasionally  met  with  as  a 
congenital  condition  due  to 
lymphatic  overgrowth  or 
enlarged  mucous  glands 
(cf.  also  N/EVUS).  When  the  deformity  is  sufficiently  serious  to  require  treat- 
ment, a  part  of  the  lip  may  be  removed  either  by  taking  out  a  wedge-shaped 
piece  of  the  whole  thickness  of  the  hp  or  by  splitting  the  lip  and  removing 
a  part  of  its  thickness  and  afterwards  stitching  together  the  edges  of  the 
mucous  membrane. 

The  more  common  acc|uired  macrocheilia  or  '  thick  lip  '  is  usually  due  to 
a  chronic  lymphangitis  which  is  frequently  seen  in  tuberculous  childi'en. 
Repeated  attacks  of  acute  or  subacute  inflammation  of  the  lymphatic  vessels 
leaves  a  permanent  thickening  of  the  lip  behind — a  condition  analogous 
to  elephantiasis. 

IVXicrostoma,  or  congenitally  small  mouth,  is  occasionally  seen,  and  even 
complete  Closure — atresia.  This  is  treated  by  enlarging  the  opening  to  the 
necessary  extent,  stitching  together  the  mucous  and  cutaneous  borders,  and 
at  the  corners  bringing  a  flap  ofmucous  membrane  across  the  angle  to  the  skin. 
Similar  operations  may  be  performed  in  cases  of  cicatricial  contraction  after 
ulceration,  burns,  &c. 

In  very  rare  cases  the  tongue  is  congenitally  absent. 

A  common  deformity,  though  not  nearly  so  common  as  it  is  popularly 
supposed  to  be,  is  tong-ue-tie  or  congenital  shortness  of  the  frjenum.  Where 
this  really  exists  the  tip  of  the  tongue  is  so  tied  down  to  the  floor  of  the 
mouth  and  inner  surface  of  the  jaw  that  it  cannot  be  protruded,  and  sucking 
is  materially  interfered  with  :  slighter  degrees  of  the  deformity  often  exist, 
while  in  rare  cases  the  tongue  is  so  bound  down  to  the  floor  of  the  mouth  as 
to  be  practically  immobile  (anchyloglossus).  Tongue-tie  is  easily  recognised 
by  pushing  up  the  tip  with  the  finger  in  the  child's  mouth  ;  its  treatment 
consists  in  snipping  through  the  edge  of  the  frsenum  with  a  pair  of  blunt- 
pointed  scissors  and  then  tearing  the  rest  with  the  finger  nail  while  the 
tongue  is  pushed  upwards.  The  division  should  be  made  near  the  jaw,  and 
^    Vide  also  fisfs.  in  Forster's  Missbildun^en  des  Mc/tscken. 


176  Diseases  of  the  Digestive  System 

should  not  be  too  free,  or  possibly  the  ranine  vessels  might  be  injured,  or  even 
it  is  said  '  tongue-swallowing '  occur,  from  loosening  of  the  tongue  muscles 
in  the  child's  subsequent  efforts  at  sucking.  A  more  probable  danger  is  the 
occurrence  of  cellulitis. 

Sometimes  the  tongue  is  malformed,  cleft  in  the  middle  line,  or  even 
trilobed,'  or  the  muscles  of  one  side  may  be  deficient,^  e.g.  as  sometimes 
in  facial  hemiatrophy. 

Subling:ual  cysts  may  develop  in  the  median  line  between  the  genio- 
hyo-glossi  as  a  result  of  persistence  of  the  lingual  duct  which  runs  from  the 
foramen  CEecum  towards  the  isthmus  of  the  thyroid ;  the  cavity  of  these 
cysts  is  lined  with  epithelium  and  contains  fatty  material^  {vide  p.  179). 

IVIacrog-lossia  is  the  term  applied  to  a  congenital  affection  of  the  tongue 
in  which  the  normal  lymph  spaces  are  greatly  enlarged  and  there  is  also  an 
overgrowth  of  the  connective  tissue  of  the  part  ;  there  is,  in  fact,  congenital 
lymphangiectasis.  The  result  of  this  is  great  enlargement  of  the  tongue, 
which  may  be  kept  protruded  from  the  mouth  to  varying  degrees,  and  by  its 
bulk  and  unwieldiness  interferes  with  sucking  and  breathing.  We  have  also 
met  with  slighter  degrees  of  the  same  condition  affecting  only  the  sublingual 
tissue  and  resembling  ranula.  Associated  commonly  with  macroglossia  is 
hygroma  or  one  form  of  '  hydrocele  of  the  neck.'  This  is  simply  a  similar 
condition  of  the  lymphatics  of  the  floor  of  the  mouth  and  upper  part  of  the 
neck.  It  appears  as  a  soft,  doughy  swelling  in  the  submaxillary  region,  and 
may  reach  a  large  size,  occupying  the  greater  part  of  the  sides  and  front  of 
the  neck  {vide  chapters  on  TuMOUR  Growth  and  on  N^vus). 

In  severe  cases  these  conditions  rarely  admit  of  successful  treatment,  the 
children  are  generally  marasmic  and  often  otherwise  malformed.  -Removal 
of  part  of  the  tongue  with  the  ecraseur  or  excision  of  a  wedge  from  it  with 
subsequent  closure  of  the  gap  may  be  attempted.  Galvano-puncture,  electro- 
lysis, setons,  and  injections  are  all  worth  thinking  of,  and  pressure  and 
astringents  are  said  to  have  done  good  in  some  instances.  Our  friend  Mr. 
Howlett  of  Hull  has  recorded  a  most  successful  case  of  the  treatment  of 
macroglossia  by  electrolysis.  The  case  v.'as  a  very  severe  one,  but  repeated 
applications,  twenty-six  in  all,  completely  cured  it  {vide  '  Quarterly  Medical 
Journal,'  October  1896).  It  must  be  remembered  that  hygroma  sometimes 
spontaneously  disappears. 

Slighter  degrees  of  the  deformity  are  occasionally  met  with  in  older 
patients  :  in  them  the  condition  has  a  less  obvious  connection  with  the 
lymphatics,  and  appears  to  be  sometimes  mere  overgrowth  of  the  mucous 
and  connective  tissues. 

Ranula  is  the  result  of  occlusion  of  a  mucous  duct  and  the  formation 
of  a  retention  cyst,  rarely  it  is  due  to  obstruction  of  a  sublingual  salivary  duct. 
It  appears  as  a  bluish-grey  translucent  swelling  beneath  the  tongue  ;  it 
is  soft,  fluctuant,  and  painless,  but  produces  deformity  from  pressure  of  the 
tongue  upwards  and  the  floor  of  the  mouth  downwards,  and,  if  large,  interferes 
with  speech  and  deglutition.  The  swelling  contains  a  clear  glairy  fluid  like 
white  of  ^^■g.  Ranula  may  be  treated  by  excision  of  a  part  of  the  cyst  wall 
or  by  passage  of  a  seton  through  it  ;  both  methods  are  frequently  successful, 

1  Barling,  Brit.  Med.  Jour.  December  5,  1885. 

2  Cholet  in  Billard's  Maladies  de  I' Enfance. 

3  Bland  Sutton,  Brit.  Med.  Jour.  February  27,  1886. 


Hypertrophy  and  Atrophy  of  the  Face  177 

but  sometimes  fail  ;  if  they  do  the  greater  part  of  the  cyst  wall  should  be 
clipped  away  with  scissors  and  the  surface  remaining  be  well  scraped  or 
rubbed  over  with  solid  nitrate  of  silver.  Relapse  is  believed  to  be  sometimes 
due  to  the  cyst  being  multilocular.  Rarer  forms  of  ranula  are  said  to  be  due 
to  enlargement  of  a  bursa  beneath  the  mucous  membrane  fbursa  of  Fleisch- 
mann),  or  of  the  one  between  the  genio-hyo-glossi  muscles — these  may  con- 
tain melon-seed  bodies.  Ranulte  connected  with  the  subma.xillary  duct  have 
often  been  described,  but  their  existence  is  more  than  doubtful  ;  the  duct  can 
always  be  made  out  lynig  on  the  surface  of  the  cyst.  Congenital  dermoid 
cysts  in  connection  with  the  branchial  clefts  are  sometimes  met  with  in  the 
floor  of  the  mouth  :  they  may  attain  a  large  size  or  remain  stationary  for 
years  ;  they  contain  the  usual  sebaceous  matter,  hair,  &c. 

A  form  of  cyst  arising  in  connection  with  the  lingual  duct  which  runs 
from  the  foramen  caecum  towards  the  hyoid  bone  has  already  been  mentioned. 
It  is  due  to  persistence  of  the  pharyngeal  diverticulum  from  which  the  thy- 
roid gland  is  developed,  the  thyro-glossal  duct.  Vide  '  Median  Fistulee  of 
Neck,' p.  J  79.  The  dermoid  and  bursal  cysts  are  to  be  treated  by  free 
incision,  with  scraping  and  subsequent  drainage  ;  in  some  cases  the  cyst 
requires  dissecting  out  through  an  incision  below  the  jaw. 

We  have  met  with  a  salivary  calculus  in  a  child. 

Other  Affections  of  tbe  tong'ue. — Papilloma  and  condyloma  of  the 
tongrue  are  not  rarely  seen,  as  well  as  nsevi  and  mucous  retention  cysts. 
Papillomata  may  be  snipped  off,  condylomata  require  of  course  specific 
treatment,  mucous  cysts  should  be  treated  like  ranula. 

Naivus  of  the  tongue  is  not  rare  {vide  chapter  on  N.EVi)  ;  puncture  with 
the  actual  cautery  is  usually  the  best  treatment,  but  excision  of  part  of  the 
tongue  may  be  required. 

Mason  has  described  congenital  pendulous  fibro-cellular  tumours  of  the 
tongue. 

Hypertrophy  and  Atrophy  of  the  Face. — In  some  cases  one  side  of 
the  face  is  congenitally  hypertrophied,  and  continues  to  grow  more  rapidly 
than  the  other  side.  Nothing  can  be  done  for  this  deformity  unless,  perhaps, 
ligature  of  the  external  carotid  were  tried. 

Congenital  Atrophy^  or  rather  arrest  of  developme7it  of  the  face,  is  also 
occasionally  seen  ;  most  often  it  is  the  result  of  either  some  cerebral  deficiency 
or  of  some  unilateral  lesion,  such,  for  instance,  as  torticollis  ;  it  may  occur  as 
an  acquired  deformity  resulting  from  injury. 

Congenital  atresia  of  the  mouth  has  been  already  mentioned,  but  in  some 
cases  the  obstruction  is  not  at  the  lips,  but  at  the  level  of  the  pillai's  of  the 
fauces,  and  is  clearly  due  to  non -absorption  of  the  septum  marking  off  the 
buccal  involution  from  the  pharynx.  If  this  rare  condition  is  met  with, 
probably  free  incision  and  dilatation  would  relieve  the  obstruction. 

Actual  absence  of  the  mouth  with  deficient  development  of  the  facial 
bones,  and  instances  of  apertures  below  the  natural  position  or  on  the  cheek, 
have  been  met  with.     {Vide  Billard,  op.  cit.) 

Ballard  has  recorded  a  case  of  deformity  of  the  jaws  produced  by  thumb- 
sucking,  the  upper  jaw  being  drawn  forwards,  and  the  lower  depressed  so 
that  the  face  is  'overhung.'  ' 

'   Path.  Soc.   Trans,  vol.  xv. 


1/8 


Diseases  of  tJie  Digestive  System 


Brancbial  Pistulae.- — Small  orifices  large  enough  to  permit  the  passage 
of  a  fine  prolDe  for  distances  varying  from  a  quarter  of  an  inch  to  two  or  three 
inches  are  sometimes  met  with  in  the  neck  on  one  side  of  the  middle  line. 
They  may  occur  in  the  immediate  neighbourhood  of  the  external  ear  or  lower 
down  in  the  neck  ;  the  most  common  position  is  said  to  be  just  above  the 
sterno-cla\'icular  joint.  The  fine  channel  continuous  with  these  openings 
usually  runs  upwards  and  towards  the  middle  line.  A  little  watery  mucous 
discharge  is  often  secreted  from  glands  lining  the  interior  of  the  passage,  and 
it  is  said  that  occasionally  there  is  a  distinct  communication  with  the  pharynx. 
These  fistulae,  which  are  often  hereditary,  may  be  single,  or  there  may  be 
two  or  three  of  them,  and  they  may  be  symmetrical.  Fragments  of  cartilage' 
may  be  found  in  their  neighbourhood,  and  it  is  possible  that  pharyngeal 
diverticula  may  result  from  patency  of  the  internal  orifice. 

The  presence  of  these  fistulas  is  due  to  imperfect  obliteration  of  the 
branchial  clefts  of  embrj^onic  life. 

The  most  remarkable  instance  we  have  seen  is  that  figured.  The  pinna 
was  deficient,  and  the  aperture  below  allowed  ready  passage  to  a  finger  into 

the  pharynx.  The  aperture 
was  closed  by  a  plastic 
operation. 

While  the  cervical  bran- 
chial fistula;  are  rare,  it  is 
quite  common  to  see  chil- 
dren in  whom  there  is  a 
small  pendulous  body,  like 
a  molluscous  growth,  upon 
the  cheek  just  in  front  of 
the  external  ear.  Some- 
times there  is  more  than 
one  of  these,  and  very  often 
at  the  base  of  the  little 
body  is  a  minute  orifice 
leading  a  short  distance 
inwards.  We  have  most 
often  seen  these  '  super- 
numerary auricles,'  as 
they  are  called,  unasso- 
ciated  with  any  other  de- 
formity ;  but  in  one  instance  the  child,  which  had  several  of  these  auricles, 
had  also  macrostoma,  double  hare-lip,  and  cleft  palate,  and  a  small  pendulous 
body  exactly  like  one  of  the  auricles  upon  the  tip  of  the  nose.  Our  friend 
Mr.  Southam  has  recorded  a  somewhat  similar  case  (fig.  26),  and  Mr.  J.  H. 
Morgan  another.     Cervical  'auricles'  are  also  met  with  {vide'ng.  28). 

The  cervical  branchial  fistute  represent  the  clefts  between  the  hyoid  and 
thyrohyoid  arches,  or  between  the  thyrohyoid  and  subhyoid,  or  again  between 
the  subhyoid  arch  and  the  upper  boundary  of  the  chest,  while  the  presence  of 
aural  fistula  occurring,  as  it  sometimes  does,  in  the  helix  or  elsewhere,  is  due 

1  Treves  records  a  case  in  which  a  rod  of  cartilage  existed,  but  no  fistula  {Path.  Soc. 
November  i,  iSSy);     We  have  seen  a  similar  case. 


Fig.  27. 


-Branchial  fistula  in  a  girl.     Traces  of  the 
pinna  are  seen  above  the  fistula. 


Ih'anchial  Fistiila;,  &€. 


179 


to  persistence  of  one  or  more  of  the  fissures  between  the  'tubercles  '  of  which 
the  pinna  is  built  up,'  the  supernumerary  auricles  themselves  representing 
displaced  or  ununited  '  tubercles.' 

The  common  '  supernumerary  auricles,  which  may  or  may  not  have  a  little 
pit  at  their  base,'  are  thought  by  Sir  J.  Paget  to  be  probably  'growths  of  the 
same  opercular  skin  fold  as  the  auricle,  from  which  they  look  like  bits  de- 
tached, or  they  are  auricles  displaced,  but  still  in  the  line  or  region  of  the 
mandibular  arch.'  - 

The  auricles,  sometimes  at  least,  contain  cartilage,  and  the  association  of 
enchondroma  of  the  parotid  occurring  in  later  life  with  disturbance  of  the 
development  of  these  parts  has  been  pointed  out  by  Mr.  Jacobson." 

In  very  rare  instances  an  orifice  is  met  with  in  the  median  line  of  the 
neck.  Of  this  we  have  seen  four  cases,  two  of  our  own  and  two  in  the 
practice  of  our  colleagues  ;  in  one  there 
was  a  seam  in  the  skin  closely  resembling 
the  scar  of  a  tracheotomy  wound,  and  in 
the  centre  of  this,  just  above  the  sternum, 
was  a  small  opening  ;  in  the  second  case 
there  was  a  discharging  fistula  over  the 
lower  part  of  the  thyroid  cartilage.  These 
median  apertures  may  be  explained  by 
failure  of  the  branchial  arches  to  close 
in  the  middle  line,  or  possibly  by  a 
deficient  closure  of  the  '  sinus  cervicalis.' 
It  is,  however,  most  probable  that  such  a 
fistula,  the  '  thyro-glossal  duct '  or  '  canal 
of  His,'  is,  in  the  words  of  Dr.  C.  F. 
Marshall,  who  has  kindly  sent  us  his 
paper  on  the  subject,  '  a  remnant  of  the 
middle  thyroid  rudiment  of  His.  It  is 
not  difficult  to  imagine,'  he  says,  '  that 
this  may  gradually  become  dilated  at  its 
lower  end  into  a  sac  by  the  secretion  of  mucus  from  the  wall  of  the  canal, 
and  that  this  sac  ultimately  causes  the  skin  to  give  way  by  its  pressure 
till  a  sinus  is  formed.'  Dr.  Marshall,  in  his  interesting  paper,  points  out 
that  these  fistulas  are  not  present  at  birth,  but  appear  later,  a  strong  point 
in  support  of  his  view,  which  is  now  generally  accepted."* 

H.  E.  Durham  in  the  '  Med.-Chir.  Trans. '  1894,  points  out  that  the  proof 
of  a  fistula  being  derived  from  the  thyro-glossal  duct  depends  upon— 

1.  A  median  position. 

2.  A  ciliated  epithelial  lining. 


Fig.  28. — Supernumerary  auricle  in  the  neck. 


1  Vide  Mr.  Bland  Sutton's  Lectures,  Brit.  Med.  Jour.  February  19,  1887,  and  Lancet, 
February  1888,  and  his  book  on  Tumours,  1893. 

-  Sir  J.  Paget  [Med.-C/iir.  Trans.  1878),  from  whose  writings  much  of  our  information 
on  the  subject  is  taken. 

■'  Vide  Gu/s  Reports. 

■*  ^^'^^  Sir  J.  Paget,  op.  cit.  ;  also  Tillaux  and  others,  Le  Progres  Midic.  February  21, 
1885  ;  Dr.  C.  F.  Marshall,  Jour,  of  Anat.  and  Phys.  vol.  x.wi.  ;  also  St.  Thomas's  Hospital 
Reports,  1890,  and  Brit.  Med.  Jour.  May  1890. 

N  2 


i8o  Diseases  of  tJie  Digestive  System 

3.  Permeability  through  the  foramen  csecum. 

4.  Paired  lumina  resulting  from  the  original  bifurcation. 

5.  The  presence  of  thyroid  gland  follicles. 

6.  A  connection  with  the  thyroid  gland  below. 
The  first  two  points  are  the  most  important. 

As  these  branchial  fistulse  give  rise  to  very  little  inconvenience,  it  is  usually 
best  to  leave  them  alone,  especially  as  they  are  intractable  to  treatment  from 
the  difficulty  of  thoroughly  destroying  their  secreting  surface.  The  passage 
of  a  hot  wire  down  them,  or  passing  a  probe  in  and  then  dissecting  round  it, 
or  the  use  of  the  galvanic  cautery,  is  the  plan  usually  advised.  In  the  second 
of  our  median  fistute,  in  which  there  was  a  '  pinching '  pain  in  the  pait,  we 
with  some  trouble  succeeded  in  obliterating  it  for  a  time  by  several  applica- 
tions of  nitrate  of  silver  fused  upon  a  wire  and  passed  well  up  the  track  ; 
subsequently,  however,  fresh  secretion  occurred,  and  even  excision  failed  to 
entirely  cure  the  condition  ;  however,  complete  excision  of  the  whole  fistula:; 
is  the  only  at  all  certain  method  of  cure,  and  this  may  involve  a  somewhat 
troublesome  dissection. 

Supernumerary  auricles  should  be  simply  snipped  off.  They  consist  of 
a  small  rod  of  yellow  elastic  cartilage  covered  with  integument,  and  are 
supplied  with  a  small  artery. 

Instead  of  fistulae,  congenital  dermoid  cysts  may  be  found  marking  the 
sites  of  the  various  fissures  &c.  of  the  embryo  {vide  chapter  on  Tumour 
Growth).  Glutton  has  described  a  case  of  congenital  papilloma  in  the  line 
of  the  branchial  fissures  ;  and  cases  of  primary  carcinoma  in  the  neck,  pro- 
bably taking  origin  in  relics  of  the  branchial  clefts,  have  been  recorded. 

In  some  of  these  patients  the  lower  jaw  is  imperfectly  developed. 

By  far  the  best  account  of  the  various  developmental  abnormalities  will 
be  found  in  Bland  Sutton's  interesting  '  Tumours,  Innocent  and  Malignant ;' 
Gassell  &  Co.   1893. 

Any  part  of  the  digestive  tract  may  be  the  seat  of  congenital  malforma- 
tion in  addition  to  those  already  described.  Gongenital  strictures  ^  and 
pouchings  ~  of  the  oesophagus,  tracheal  fistula,^  displacements  of  the  stomach, 
obliteration  of  the  pylorus,  absence  of  portions  of  the  intestinal  canal,  and 
displacement  of  its  various  segments,  are  all  met  with,  and  in  certain  cases 
may  have  some  surgical  importance  ;  they  cannot,  however,  be  discussed 
here.  We  have  recorded  a  case  of  pouching  of  the  oesophagus  which  was 
probably  congenital  and  inherited,  inasmuch  as  mother  and  son  both  appa- 
rently had  it.  Mr.  Butlin  has  also  recently  recorded  cases.  Enterotomy 
might  possibly  be  of  service  in  some  cases  of  congenital  intestinal  deformity 
where  the  obstruction  >vas  low  down  {vide^.  148). 

1  Charlewood  Turner  mentions  seven  cases  in  Ziemssen.  Vide  Path.  Soc.  Trans. 
1885. 

2  Sir  Morell  Mackenzie  states  that  congenital  pouching  is  extremely  rare. 

^  May  be  combined  with  oesophageal  deficiency  usually  at  the  middle  third  of  the 
gullet.     The  fistula  is  a  persistence  of  the  embryonic  condition  (Sir  M.  Mackenzie). 


I8I 


CHAPTER   X 

DISEASES    OF    THE    LIVER 

In  examining  the  liver  of  an  infant  or  young  child,  it  must  be  borne  in  mind 
that  this  organ  is  proportionately  larger  in  the  child  than  in  the  adult  ;  it 
consequently  occupies  a  greater  space  in  the  abdominal  cavity,  and  thus  to 
the  inexperienced  it  may  appear  to  be  enlarged,  when  in  reality  it  is  only  of 
normal  size.  The  fact  pointed  out  by  Sahli  must  not  be  forgotten,  namely, 
that  the  angle  made  by  the  lower  ribs  with  the  tip  of  the  sternum  is  wider  in 
children  than  adults,  so  that  more  of  the  liver  is  left  uncovered  in  the  former 
than  in  the  latter. 

The  upper  limit,  as  determined  by  percussion,  reaches  to  the  fifth  space 
at  the  right  edge  of  the  sternum,  to  the  upper  border  of  the  sixth  rib  in  the 
nipple  line,  the  seventh  in  the  axillary,  and  the  ninth  posteriorly,  though  the 
deep  dulness  reaches  somewhat  higher.  While  the  edge  of  the  right  lobe 
does  not  in  an  adult  extend  below  the  costal  arch  in  the  recumbent  position, 
in  a  child  it  always  does.  The  size  of  the  liver  can  be  as  readily  estimated 
in  a  child  as  in  an  adult  by  percussion  if  the  stomach  is  not  over-distended  ; 
the  lower  edge  can,  however,  be  much  more  readily  felt  in  a  child  than  in  an 
adult  by  placing  the  warm  hand  on  the  abdomen  and  gently  pressing  back- 
wards and  upwards.  In  most  cases  it  can  be  easily  determined  if  the  edge 
is  round,"  sharp,  irregular,  or  flabby  as  in  acute  yellow  atrophy. 

The  liver  is  not  often  smaller  than  natural  during  childhood  ;  it  is  so  only 
jn  the  rare  instances  of  the  occurrence  of  acute  yellow  atrophy  or  cirrhosis, 
and  even  in  these  cases  it  is  frequently  enlarged,  a  result  which  is  due  partly 
to  its  vascular  nature,  its  veins  being  very  readily  distended,  and  partly  also 
to  the  ready  way  in  which  it  appears  to  store  away  fat. 

The  best  instance  of  its  enlargement  from  mechanical  causes  is  afforded 
by  the  congestion  which  so  frequently  attends  heart  disease,  where,  in  conse- 
quence of  regurgitation  through  the  mitral  valves,  there  is  an  obstruction  to  the 
onward  flow  of  the  blood.  It  is  enlarged  also  in  mediastino-pericarditis  for 
a  similar  reason.  There  appears  also  often  to  be  a  temporary  enlargement 
and  a  sluggish  circulation  in  many  cases  of  chronic  intestinal  catarrh,  where 
"there  is  said  to  be  a  functional  derangement  of  the  Hver,  accompanied  by  loss 
of  appetite  and  pasty  constipated  stools  deficient  in  bile  and  an  excess  of 
pigment  and  perhaps  uric  acid  in  the  urine.  The  liver  is  frequently  enlarged 
from  the  presence  of  excess  of  fat ;  more  rarely  it  is  amyloid,  or  the  seat  of 
'new  growths  or  of  abscess. 

The  weight  of  the  liver  at  birth  is  about  4^  oz.  or  4-2  per  cent,  of  the  body 


1 82  Diseases  of  the  Liver 

weight  ( Birch- Hirschfeld).  At  a  year  old  1 1  oz.  or  3-4  per  cent,  of  the  body 
weight  (Holt).  In  the  adult  the  weight  of  the  liver  is  2'5  percent,  of  the  body 
weight  (Frerichs). 

Jaundice 

The  common  form  of  jaundice  occurring  in  newly  born  infants  has  already 
been  discussed  ;  the  rarer  form  in  which  jaundice  is  due  to  lesion  of  the  bile 
ducts  may  be  here  referred  to. 

Cong-enital  Stricture  or  Obliteration  of  the  Bile  Ducts. — In  these 
curious  cases  an  obliteration  of  the  common  hepatic  ducts  appears  to  take 
place,  which  leads  to  a  secondary  or  biliary  cirrhosis  of  the  liver  if  the  infant 
survive  for  afew  months.  The  child  may  die  from  liEemorrhage  from  the  navel 
or  gastro-intestinal  canal  during  the  first  few  days  of  life.  Such  cases,  though 
not  common,  are  by  no  means  rare.  Among  the  more  recently  recorded  cases 
are  those  of  Wickham  Legg,  Glaister  and  John  Thomson  \  we  have  seen 
several  cases  in  which  autopsies  were  made. 

Syniptoins. — The  infant  is  jaundiced  from  birth,  the  yellow  colour  being 
intense,  affecting  the  skin,  conjunctivEe,  mucous  membrane,  and  urine ;  the 
stools  are  pale  and  completely  devoid  of  bile.  The  infant  frequently  suffers 
from  hsemorrhages,  the  stools  then  being  black  and  the  skin  covered  with 
ecchymoses.  In  one  of  our  cases  the  motions  were  stated  by  the  mother  to 
be  black  immediately  afterbirth.  The  liver  may  be  enlarged.  Such  children 
may  hve  for  a  few  months  ;  two  of  our  cases  lived  to  be  /i^\  months  old.  The 
following  case  illustrates  some  of  these  points. 

Congeiiital  Absence  of  Hepatic  Ducts.  Biliary  Cirj'hosis. — ^John  H.,  aged  6  weeks,  was 
brought  to  the  out-patient  department  on  October  4,  1883,  with  the  following  history  : 
Mother  states  he  was  an  eight-months  child,  born  after  a  tedious  labour.  About  a  week 
after  birth  it  was  noticed  he  was  jaundiced  (midwife  states  he  was  yellow  when  born) ;  his 
urine  was  dark  and  stained  the  linen  ;  the  stools  were  loose  and  pale  grey  in  colour ;  he 
did  not  '  snuffle,'  and  there  never  was  any  rash.  On  e.xamination,  when  6  weeks  old,  he 
was  deeply  jaundiced ;  fairly  well  nourished  ;  the  edge  of  the  liver  was  felt  immediately 
below  the  ribs.  October  8. — Much  the  same  ;  diarrhoea  troublesome,  pale  white  milky 
stools.  October  25. — The  liver  is  enlarged,  the  edge  being  felt  nearly  on  a  level  with  the 
umbilicus  ;  it  has  been  increasing  in  size  the  past  week  or  two.  November  i. — Liver  still 
enlarged  ;  stools  loose,  resembling  milk  ;  still  intensely  jaundiced  ;  is  becoming  very  thin, 
December  6. — Liver  decidedly  less;  diarrhoea  not  so  troublesome;  continues  to  waste. 
December  30. — Diarrhcea  has  been  very  troublesome  ;  convulsions.  Death  when  4  months 
old.     He  had  not  at  any  time  suffered  from  purpura  or  hsemorrhages. 

Post-mortem. — Body  extremely  emaciated  and  deeply  jaundiced  ;  all  internal  tissues 
bile-stained.  Heart,  muscular  walls  pale  yellow ;  kidneys  ditto.  Liver,  7  oz.  ;  does  not 
appear  enlarged  ;  is  of  a  dirty  dark  green  colour,  surface  finely  granular  ;  no  adhesions  or 
peri-hepatitis  or  matting  of  parts  in  the  fissure  ;  it  has  a  tough  feel,  and  creaks  under  the 
knife  as  it  is  cut ;  the  section  shows  a  dark  green  colour  with  strands  of  fibrous  tissue,  much 
in  excess  of  the  normal  state,  accompanying  the  portal  vessels  ;  the  strands  are  best  marked 
near  the  entrance  of  the  vessels  at  the  fissure,  and  the  larger  bile  channels  are  more  or 
less  dilated  and  contain  thick  green  bile.  On  examining  the  inferior  surface  of  the  liver, 
the  gall  bladder  is  seen  distended  with  a  non-biliary  mucoid  fluid  ;  its  duct  can  be  traced 
downwards,  though  smaller  than  normal,  to  the  ductus  choledochus  ;  the  latter  joining  the 
duodenum  in  the  normal  position  is  pervious  and  contains  mucus  only.  No  trace  of  a 
right  or  left  hepatic  duct  can  be  found.  The  portal  vein  and  hepatic  artery  are  apparently 
cjuite  normal.  Microscopical  examination  of  liver  shows  excess  of  fibrous  tissue  sur- 
rounding portal  vessels  and  lobules ;  many  small  biliary  ducts  are  seen  choked  with 
inspissated  bile. 


Congenital  and  CatarrJial  Jaundice  1 83 

Diag?iosis. — The  olDstructive  jaundice  of  the  newly  born  can  be  readily 
distinguished  from  functional  jaundice,  the  only  form  likely  to  be  confounded 
with  it,  by  the  stools  in  the  former  being  colourless  wliile  the  latter  contain 
bile. 

Morbid  Aftatojiiy. — There  is  much  emaciation,  the  internal  organs  are 
intensely  bile-stained,  with  minute  haemorrhages  on  their  surfaces.  The 
liver  is  mostly  enlarged  and  of  a  dirty  green  colour  ;  the  surface  is  granular, 
the  granulations  varying  in  size  from  a  millet  seed  to  a  hemp  seed  :  it  has  a 
tough  feel,  and  on  section  an  excess  of  fibrous  strands  is  seen  accompanying 
the  portal  vessels — this  is  most  marked  at  the  great  fissure  ;  the  larger 
biliary  channels  contain  green  inspissated  bile.  On  examining  the  vessels 
in  the  transverse  fissure,  the  vein  and  artery  are  intact,  but  the  gall  bladder 
is  usually  small  and  contains  no  bile,  and  the  common  and  hepatic  ducts  are 
either  shrivelled  up  and  nearly  obliterated  or  greatly  diminished  in  size. 
Microscopical  examination  of  such  livers  shows  biliary  cirrhosis.  The 
etiolog"y  of  these  cases  is  obscure  ;  in  some  cases  apparently  the  ducts  are 
never  formed.  In  one  of  our  cases  the  mother  had  suffered  from  syphilis, 
but  neither  of  the  infants  showed  any  symptoms.  It  is  possible  that  a 
catarrh  of  the  bile  ducts  occurring  during  fcetal  life  or  a  blockage  from 
inspissated  bile  might  lead  to  a  permanent  obstruction  and  obliteration. 
The  cirrhosis  follows  as  a  result. 

Prognosis.- — Such  cases  are  necessarily  fatal  in  a  few  months,  and  hardly 
admit  of  any  treatment. 

Obliteration  or  Stenosis  of  the  Common  Bile-duct  occurs  during 
childhood  apparently  as  the  result  of  an  inflammatory  lesion  in  the  lower 
part  of  its  course  ;  the  head  of  the  pancreas  may  also  be  involved.  In  one  of 
our  cases  a  girl  of  5  years  became  jaundiced  for  the  first  time  when  recover- 
ing from  whooping  cough  ;  she  remained  jaundiced  till  her  death  seven 
months  after  ;  death  took  place  from  haemorrhage  into  the  bowels.  At  the 
post-mortem  the  lower  portion  of  the  common  duct  was  found  surrounded 
by  fibrous  tissue,  and  would  only  admit  a  probe  of  one  millimetre  in  diameter. 
The  head  of  the  pancreas  was  indurated  ;  the  gall  bladder  was  very  small 
and  contained  mucus  only.  In  a  second  case,  that  of  a  girl  seven  years 
of  age,  there  w^as  jaundice  for  three  years  before  death.  In  this  case  oblitera- 
tion of  the  lower  portion  of  the  common  duct  had  taken  place  and  a  gradual 
dilatation  of  the  biliary  tract  above,  which  formed  into  an  enormous  bile 
containing  cyst.  This  was  tapped  and  drained  during  life  ;  death  was  the 
i^esult  of  an  attempted  operation  to  connect  the  cyst  with  the  duodenum.^ 

Catarrhal  Jaundice. — Children  of  all  ages  are  apt  to  suffer  from  a 
temporary  jaundice,  associated  with  gastro-intestinal  catarrh,  attributable  to 
a  swollen  condition  of  the  mucous  membrane  of  the  duodenum  and  common 
bile  duct. 

Symptoms. — After  a  few^  days,  in  which  there  are  symptoms  of  dyspepsia, 
the  conjunctivae  and  skin  become  yellow,  the  urine  contains  much  pigment 
and  the  stools  are  pale.  A  few  days  later  the  liver  may  be  felt  to  be  en- 
larged. There  are  rarely  the  nausea,  low  temperature,  and  slow  pulse  so 
often  seen  in  the  catarrhal  jaundice  of  adults.     We  have,  however,  seen  one 

1  See   Medical   Chronicle,    Oct.    1898,  and  also  case   of  Treves,  Practitioner,    Jan. 


1 84  Diseases  of  the  Liver 

or  two  cases  in  which  there  were  jaundice,  deHrium,  drowsiness,  and  slight 
fever,  in  which  we  suspected  acute  yellow  atrophy,  yet  they  finally  recovered 
and  we  were  left  in  doubt  as  to  their  nature.  As  a  rule,  in  the  course  of  a 
few  days  or  a  week  all  the  symptoms  disappear. 

The  diagnosis  of  catarrhal  jaundice  does  not  usually  give  rise  to 
difficulty  when  it  occurs  in  children.  The  possibility  of  the  jaundice  being 
due  to  acute  yellow  atrophy  must  be  borne  in  mind,  and  any  ecchymoses 
or  brain  symptoms  would  be  very  suggestive  of  the  latter.  Jaundice 
due  to  cirrhosis,  or  new  growth,  or  syphilitic  disease,  could  hardly  be 
mistaken,  as  jaundice  under  these  circumstances  would  not  be  an  early 
symptom.  It  is  possible  that  jaundice  may  be  due  to  round  worms  finding 
their  way  into  the  duodenum,  and  entering  the  common  duct. 

Treatment. — The  treatment  of  catarrh  of  the  bile  ducts  should  be  similar 
to  that  of  gastric  catarrh  :  the  diet  consisting  of  beef  tea,  bread  sops,  light 
puddings,  and  milk.  Sulphate  or  phosphate  of  soda  may  be  given  with 
infusion  of  rhubarb  two  or  three  times  a  day,  Carlsbad  salts  or  Friedrichs- 
hall  water  are  useful  in  keeping  the  bowels  open. 

Epidemic  or  Infectious  Jaundice. — On  one  or  two  occasions  we  have 
observed  limited  outbreaks  of  jaundice  in  children,  accompanied  with  vo- 
miting and  fever.  On  one  occasion  this  occurred  among  visitors,  chiefly 
children,  at  a  seaside  resort  in  August.  In  some  instances  jaundice  appears 
to  have  been  a  symptom  in  some  influenza  epidemics.  Kissel  and  some 
other  authors  have  described  attacks  beginning  with  fever,  headache, 
shivering,  vomiting,  then  jaundice  supervening  in  a  few  days.  The  liver  is 
enlarged  ;  the  stools  in  some  cases  retained  their  normal  colour.  In  some 
cases  there  appears  to  be  albuminuria.  But  little  is  known  about  these 
attacks. 

Acute  Yellow  Atrophy  of  tbe  ILiver 

This  curious  and  interesting  disease  appears  to  occur  at  all  periods  of 
life,  infancy  and  childhood  not  excepted.  Several  Continental  writers  have 
described  cases  occurring  in  infants  a  few  days  old,  but  whether  these  were 
in  reality  true  cases  of  yellow  atrophy  may  be  open  to  doubt.  Undoubtedly 
infants  who  are  jaundiced  shortly  after  birth  die  in  the  course  of  a  few  days 
or  weeks  with  symptoms  of  acute  disease,  but,  as  far  as  can  be  judged  from 
the  reports,  the  naked-eye  appearances  of  the  liver  after  death  were  not 
those  usually  found  in  acute  yellow  atrophy.  In  such  obscure  diseases  as 
those  named  after  Buhl  and  Winckel,  jaundice  occurs.  While  this  disease 
cannot  be  said  to  be  common  at  any  time  of  life,  it  is  perhaps  rarer  in 
childhood  than  in  early  adult  or  middle  life,  though  it  is  very  probable  that 
cases  are  not  infrequently  overlooked,  inasmuch  as  some  of  the  recorded 
cases  were  not  diagnosed  during  life.  That  they  are  not  rare  is  certain,  as 
Dr.  Hyla  Greves  has  collected  seventeen  cases  beside  one  observed  by 
himself.  We  have  seen  several  cases,  one  of  which  occurred  in  a  boy  of  four 
years,  another  in  a  girl  3^  years,  and  we  have  had  the  opportunity  of  examin- 
ing the  liver  in  a  case  of  Dr.  Railton's. 

Symptoms. — -The  disease  begins  insidiously  ;  the  first  symptoms  are 
chiefly  those  of  catarrhal  jaundice,  loss  of  appetite,  constipation,  and  jaundice, 
the  stools  are  mostly  pale  but  sometimes  quite  normal,  and  the  urine  is  bile- 


Acute    Ye/low  AtropJiy  of  the  Liver  185 

stained.  The  patient  usually  remains  in  this  condition  for  a  week  or  two, 
during  which  time  neither  his  friends  nor  medical  attendant  suspect  the 
serious  nature  of  the  disease.  The  liver  at  this  period  is  enlarged  and  in  some 
cases  distinctly  tender,  the  edge  may  have  a  flabby  feel.  Then  come  distinct 
cerebral  symptoms  which  may  not  improbably  be  mistaken  for  the  onset  of 
tubercular  meningitis.  The  child  is  irritable,  vomits  repeatedly,  rambles  at 
night,  is  perhaps  \ery  delirious  or  convulsed  ;  the  pupils  are  generally  dilated. 
There  are  often  ecchymoses  about  the  body  at  the  seat  of  slight  injuries,  and 
oozing  of  blood  from  the  gums  and  oedema  of  the  feet  and  face.  x'\fter  a 
few  days  the  child  passes  into  a  condition  of  coma  ;  there  are  also 
probably  muscular  twitchings,  spasms  of  several  groups  of  muscles  as  the 
masseters,  and  perhaps  local  paralyses.  The  urine  may  contain  leucin  and 
tyrosin.  In  the  latter  stages  the  liver  diminishes  in  size,  but  this  is 
not  invariably  the  case.  The  following  case  illustrates  some  of  these 
points  : 

Acute  Yellow  Atrophy  of  Liver. — Stephen  T. ,  aged  4  years.  Admitted  September  27, 
1882.  Mother  dead.  No  history  of  congenital  syphilis  could  be  obtained.  Father  is  a 
labourer  in  poor  circumstances.  Child  has  been  much  neglected,  and  often  had  insufficient 
food.  Four  weeks  before  admission  child  took  ^•e^y  little  nourishment ;  became  yellow 
and  was  constipated.  Fourteen  days  ago  vomiting  began,  and  lately  he  had  been  delirious 
at  night  and  queer  in  his  ways.  Present  state. — Patient  is  a  well-developed  boy  ;  moderate 
jaundice ;  there  is  oedema  of  both  eyelids,  back  of  hands,  and  dorstmi  of  both  feet.  He 
is  frequently  mumbling  to  himself,  and  does  not  readily  understand  what  is  said  to  him. 
His  tongue  is  red  at  the  tip  and  edges  and  coated  on  dorsum  ;  he  is  very  thirsty,  but 
almost  constantly  vomits  his  milk  immediately  after  it  is  taken.  Abdomen  somewhat  dis- 
tended ;  edge  of  liver  distinctly  felt  below  costal  arch  and  in  epigastrium,  and  on  per- 
cussion dulness  extends  upwards  to  the  fourth  space.  The  tip  of  the  spleen  is  felt  below 
the  tenth  rib.  Heart's  sound  normal ;  no  marked  physical  sign  in  chest.  Urine  passed 
with  fseces  or  in  bed  ;  some  separated  from  fasces  contained  bile  pigment ;  no  albumen  ; 
no  leucin  or  tyrosin  under  microscope.  Fseces,  passed  a  few  hours  after  admission,  were 
solid  and  of  a  dark  brown  colour.  Pupils  dilated,  but  act  to  light.  Pulse,  100,  weak  ; 
temperature,  99°  F.  Second  day  (of  admission). — Vomiting  continued  most  of  day,  but 
less  after  peptonised  milk  was  given.  Temperature,  95'4°-ioo-2°.  Third  day. — Less 
vomiting ;  "haemorrhage  from  mouth,  apparently  from  gums  ;  bowels  acted  once  after 
calomel,  solid  brown  motion  ;  no  urine  passed  for  twenty-four  hours.  Temperature, 
96°-ioi'2°,  97-8°-io2-8°.  Fourth  day. — Child  has  been  delirious,  with  some  muscular 
twitchings  of  face  and  neck.  This  morning,  left  facial  paralysis  noticed  not  affecting  the 
eye  ;  it  is  well  marked  when  child  cries,  but  not  complete  ;  no  paralysis  elsewhere  ;  pupils 
dilated  and  sluggish  ;  child  only  semi-conscious  ;  several  loose  stools  passed  after  calomel, 
the  first  light  yellow,  later  pale  grey  colour ;  no  urine  obtained  ;  edge  of  liver  very  dis- 
tinctly felt  below  costal  arch.  Pulse,  100,  weak;  temperature,  io2'8°,  104°,  io2'6°,  101°. 
Fifth  day. — Much  worse  ;  is  quite  unconscious  ;  head  and  eyes  turned  to  right ;  all  limbs 
extended  and  rigid  ;  spasms  of  jaws  causing  constant  grinding  of  teeth ;  breathing 
stertorous  ;  no  optic  neuritis,  but  veins  are  full  and  somewhat  tortuous.  Pulse,  130,  weak  ; 
terriperature,  ioi'2°-ioo°.     Died  in  afternoon. 

Post-mortem  (twenty-two  hours  after  death). — Body  well  nourished  ;  skin  very  yellow  ; 
much  hypostatic  congestion  of  dependent  parts  of  the  back  and  arms  and  legs  ;  '  coffee- 
ground  '  material  oozing  from  mouth  ;  no  rigor  mortis  ;  slight  oedema ;  a  bruise  about 
size  of  a  penny  is  visible  on  the  sub-clavicular  region,  left  side.  Chest :  no  fluid,  old 
adhesions  left  side  ;  right  lung  on  section  showing  numerous  small  haemorrhages  into  sub- 
stance of  lung  ;  both  lobes  are  gorged.  Left  lung :  there  is  a  solid  portion  in  upper 
lobe,  reaching  anterior  surface  and  corresponding  in  a  position  with  above-mentioned 
bruise,  involving  the  whole  thickness  of  the  lobe,  but  not  the  inner  or  outer  edges.  On 
section  this  solid  portion  consists  of  red  hepatisation  with  a  blood  clot  in  centre  and  at 


1 86  Diseases  of  the  Liver 

circumference  ;  lower  lobe  gorged  and  containing  small  haemorrhages.  Bronchi  contain 
blood  and  mucus.  Heart,  2 J  oz.  :  left  side  contracted,  containing  a  few  strings  of  yellow 
fibrin  ;  walls  of  heart  pale  yellow  and  fatty  ;  no  endocarditis  ;  haemorrhages  into  sheath  of 
aorta.  Abdomen  :  on  opening,  a  few  ounces  of  bile-stained  fluid  escaped.  Much  injection 
of  small  vessels  of  mesentery  in  the  neighbourhood  of  the  liver  ;  one  haemorrhage,  size 
of  walnut,  in  mesenter}'  of  descending  colon.  Stomach  contained  coffee  grounds  ; 
duodenum  also  darkish  contents  ;  rest  of  small  and  large  intestines  contained  pale  yellow 
semi-fluid  contents.  Spleen,  3  oz.,  firm:  somewhat  enlarged  but  normal.  Kidneys, 
4g  oz.  :  cortex  pale  yellow,  and  has  a  glistening  appearance  from  presence  of  fat ;  pyramids 
congested.  B?-ain  :  nothing  abnormal  at  base,  but  convolutions  on  upper  surface  are 
decidedly  flattened  ;  the  \^entricles  are  distended  with  turbid  fluid,  and  the  parts  around, 
especially  the  ^^■hite  portions,  are  softened  and  easily  wash  away  under  a  stream  of  water  ; 
no  lesion  of  pons  or  softening  noted  elsewhere  ;  no  haemorrhage.  Liver,  12^  oz.  :  it  is 
very  limp,  and  capsule  wrinkles  on'  doubling  up.  Right  lobe  :  upper  and  lower  surfaces 
are  irregular  from  presence  of  some  portions  which  are  more  elevated  than  others  ;  the 
more  elevated  portions  are  greenish  yellow,  and  the  others  red.  On  section,  bright 
orange-yellow  and  red  portions  are  seen  ;  the  lobules  are  not  readily  seen  in  the  yellow 
parts,  which  are  soft.  In  the  red,  which  are  firmer,  the  lobes  can  be  distinguished,  the 
centres  being  bright  red  and  the  circumference  pale.  The  left  lobe  contains  more  of  the 
red  parts  and  the  right  more  yellow.  Microscopical  examination. — Red  portions,  the 
intralobular  veins  are  normal,  the  walls  of  the  interlobular  veins  contain  numerous 
leucoc3rtes,  and  the  surrounding  connective  tissue  is  also  infiltrated  ;  the  lobules  contain 
no  hepatic  cells,  but  hj-perplastic  stroma,  leucocytes,  man}' red  corpuscles.  The  biliary 
capillaries  are  \-er\'  prominent  objects,  and  seem  to  contain  epithelium  with  nuclei  under- 
going subdivision.  Yellow  portion — The  lobules  are  large  ;  central  vein  normal ;  hepatic 
cells  swollen  ;  nuclei  obscured  ;  fine  granular  contents  and  bile  pigment.  The  walls  of 
interlobular  veins  infiltrated  with  leucocytes.     Biliary  capillaries  stuffed  with  epithelium. 

Diagnosis. — Malignant  jaundice  in  an  early  stage  cannot  be  distinguished 
from  catarrhal  jaundice  ;  it  is  only  when  cerebral  symptoms  appear,  and 
there  are  dilated  pupils,  ecchymoses,  or  constant  vomiting,  that  the  suspicion 
is  raised  that  there  is  something  more  than  simple  jaundice.  At  this  time 
the  case  is  liable  to  be  mistaken  for  meningitis,  though  the  presence  of 
jaundice  and  cerebral  sjmrptoms  should  indicate  the  true  nature  of  the  dis- 
ease. It  may  possibly  be  confounded  with  pyaemia,  phosphorus  poisoning, 
or  pneumonia  with  jaundice,  but  in  all  these  the  jaundice  would  as  a  rule 
follow  and  not  precede  the  other  symptoms. 

Morbid  Anatomy. — Organs  bile-stained  ;  haemorrhages  in  various  organs. 
Liver  small,  limp  in  texture,  mostly  bile-stained,  some  portions  being  greenish 
yellow,  others  orange-red,  often  bulging  in  some  parts  from  shrinking  in 
others.  On  section,  there  are  usually  areas  of  red  or  yellow  colour  in  which 
•the  lobules  are  indistinct  or  entirely  indistinguishable. 

Ti'eat)ne7tt. — Unfortunately  but  little  can  be  said  under  this  head,  as 
such  cases  have  been  invariably  fatal. 

Cirrbosis  of  the  Jbiver 

Cirrhosis  of  the  liver  is  not  a  common  disease  during  early  life,  being- 
much  rarer  than  among  adults.  Toedten  met  with  it  thirteen  times  out  of 
8S0  post-mortems  made  during  seven  years  at  the  Children's  Hospital  at 
Munich.  Of  the  various  causes  of  cirrhosis  alcoholism  necessarily  takes  the 
first  place.  Cases  of  alcoholic  cirrhosis  have  been  reported  by  various 
authors,  Frerichs,  Bamberger,  Toedten,  Howard,  and  others.     Sir  S.  Wilks 


Cirr/iosis  of  the  Liver  187 

has  recorded  the  case  of  a  girl,  aged  8  years,  who  had  taken  daily  for  some 
time  half  a  pint  of  gin.  Sypbilis  is  by  far  the  commonest  cause  of  an 
interstitial  hepatitis  occurring  in  early  life,  more  especially  during  infency,  the 
liver  being  enlarged  and  the  infant  jaundiced,  but  it  is  doubtful  if  syphilis 
gives  rise  to  the  typical  hobnail,  cirrhotic  liver.  Gumma  of  the  liver 
may  make  their  appearance  about  puberty,  and  cicatrisations  are  formed 
which  may  involve  the  portal  vein  and  give  rise  to  ascites.  There  is  little 
evidence  to  point  to  the  interstitial  hepatitis  of  infancy  passing  on  into  the 
typical  hobnail  liver  seen  occasionally  in  older  children.  Possibly  the 
slighter  forms  of  it  which  are  not  fatal  do  so.  Tuberculosis,  especially  of 
the  peritoneum  and  abdominal  organs,  occasionally  gives  rise  to  a  peri- 
hepatitis and  also  cirrhosis  of  the  liver.  It  must  be  said,  however,  in  a 
goodly  number  of  cases  of  cirrhosis  of  the  liver  during  childhood,  there  is 
no  history  of  alcoholism  or  syphilis,  nor  any  evidence  of  tuberculosis.  Such 
cases  have  been  reported  by  Mitchell  Clarke,  W.  Edwards,  and  others. 
In  some  of  these  cases  the  symptoms  of  cirrhosis  have  been  preceded  by 
attacks  of  one  of  the  fevers,  as  enteric,  scarlet  fever,  whooping  cough,  and 
it  has  been  suggested  that  there  is  more  than  a  casual  connection  between 
the  two.  However,  considering  the  great  frequency  of  these  fevers  and  the 
rarity  of  cirrhosis,  great  caution  is  required  in  drawing  any  conclusions.  In 
a  certain  number  of  cases  perihepatitis  is  found  without  marked  cirrhosis,  as 
in  chronic  peritonitis,  pleurisy,  pericarditis  and  mediastinitis.  Syniptonis 
and  course. — The  symptoms  are  mostly  those  found  in  the  adult.  Dyspepsia, 
slight  jaundice,  epistaxis,  anaemia  and  marked  enlargement  of  the  spleen,  and 
later  ascites.  Often  the  evening  temperature  is  raised  a  degree  or  two. 
The  course  is  usually  chronic  ;  the  ascitic  fluid  forming  again  and  again 
after  being  tapped  ;  death  being  preceded  by  coma.  The  commonest  cause 
of  ascites  during  early  life  is  tubercular  peritonitis  ;  the  next  commonest 
cause,  apart  from  cardiac  and  renal  disease,  is  mediastinitis.  Ascites  with 
enlarged  spleen  is  usually  due  to  cirrhosis,  and  would  mostly  distinguish  an 
ascites  due  to  cirrhosis  from  chronic  tubercular  peritonitis  or  mediastinitis. 
We  have 'seen  several  cases  in  which  the  diagnosis  of  'enlarged  spleen' 
was  made  and  which  eventually  turned  out  to  be  cirrhosis  of  the  liver. 

Morbid  A7iatomy. — The  Hver  may  be  found  either  enlarged  or  atrophied, 
but  usually  the  former.  The  surface  is  hobnailed,  and  the  liver  creaks  on 
section.  In  syphilitic  livers  there  may  be  gummata,  cicatricial  depressions 
and  bands  of  fibrous  tissue  running  irregularly  through  the  liver  substance. 

Treatmejit. — The  treatment  of  portal  obstruction,  the  result  of  a  cirrhotic 
liver,  is  only  palliative,  for  there  is  but  little  reason  to  hope  that  even  in  syphi- 
litic disease  there  is  much  chance  of  modifying  in  any  way  the  fibrous  tissue 
which  is  strangulating  the  portal  channels  in  the  liver.  Relief  must  be  sought 
by  unloading  the  portal  system  by  purgatives  and  diuretics  and  by  removing 
the  ascitic  fluid  by  tapping  ;  the  latter  is  best  performed  by  means  of  Southey's 
tfochars.  In  syphilitic  cases  the  local  inunction  of  mercurial  ointment  and 
other  specific  treatment  should  be  tried. 

The  following  case  of  cirrhosis  of  the  liver  illustrates  the  above  remarks  : 

Cirrhosis  of  Liver. — Bertha  S. ,  aged  lo  years,  was  admitted  to  the  Children's  Hospital, 
Manchester,  November  5,  1894.  It  was  stated  that  the  patient  had  had  measles,  whoop- 
ing cough,  enteric  and  scarlet  fever  ;    the  latter  when   eight  years  of  age,  followed  by 


1 88  Diseases  of  the  Liver 

nephritis  and  dropsy.  The  child's  mother  is  addicted  to  alcohol,  and  has  been  in  a  '  Retreat ; ' 
the  child  herself  has  never  had  alcohol  given  her.  Her  present  illness  began  with  jaundice 
about  fourteen  months  ago,  then  the  abdomen  began  to  swell.  Present  state. — She  is  a 
fairly  nourished  girl,  with  slight  jaundice,  no  ascites  or  anasarca.  Gums  swollen  and  spongy, 
and  bleed  easil}^  The  edge  of  the  liver  cannot  be  felt,  the  spleen  is  much  enlarged,  the 
inner  border  can  be  felt  reaching  forward  nearly  to  the  umbilicus  and  down  to  the  iliac 
crest.  No  abdominal  tenderness.  Examination  of  the  blood  shows  4,230,000  red  cor- 
puscles per  cub.  cent.,  normal  in  size  and  shape.  No  excess  of  leucocytes.  Haemo- 
globin, 49  per  cent.  No  albumen  in  the  urine.  Other  organs  healthy.  Later  in  the 
month  it  became  evident  there  was  ascites.  There  was  also  some  smart  epistaxis  on  one 
occasion.  The  ascites  became  more  marked,  and  on  December  4  she  was  tapped  with  a 
Southey's  cannula  and  some  nine  pints  withdrawn.  After  the  tapping  the  spleen  was  felt 
as  before,  but  the  edge  of  the  liver  was  not  felt.  She  was  tapped  three  times  in  December, 
thirty  pints  being  withdrawn  in  all.  In  January,  thirty-six  pints  were  withdrawn.  In 
February,  twenty-eight  pints.  She  died  on  March  23,  having  been  comatose  for  several 
days.  Throughout  her  illness,  the  evening  temperature  rose  to  100  F. ,  but  was  normal 
in  the  morning.  No  albumen  was  ever  found,  nor  was  there  any  general  oedema.  At  the 
post-mortem  there  was  no  perihepatitis  ;  the  liver  was  small,  weighing  155  oz.  Both 
surfaces  were  irregular,  showing  small  hobnail  projections.  On  section  the  substance 
was  tough,  and  bands  of  fibrous  tissue  were  seen  rumiing  through  the  section.  The  spleen 
was  enormously  enlarged  and  solid.  Weight  13^  oz.  There  were  one  or  two  small  granu- 
lations on  the  mitral  valve. 

Syphilitic  Interstitial  Hepatitis. — The  liver  is  frequently  found  en- 
larged in  infants  suffering  from  hereditary  syphilis,  more  especially  during  the 
exanthematous  stage,  or  it  may  be  enlarged  in  newly  born  syphilitic  infants. 
Hochsinger  noted  enlargement  of  the  liver  in  46  out  of  148  cases,  of  which 
30  got  well  and  16  died.  In  the  most  marked  cases,  especially  if  the  infant 
is  poorly  nourished,  the  outline  of  the  enlarged  liver  may  be  seen,  as  well  as 
the  edge  distinctly  felt.  The  edge  is  smooth  and  the  liver  feels  hard. 
The  spleen  is  also  enlarged.  Ascites  hardly  ever  occurs  and  jaundice  is 
rare,  though  a  slight  yellowish  tint  of  the  conjunctiva  is  sometimes  present. 
The  liver  at  the  post-mortem  in  typical  instances  is  found  enlarged,  of  a 
tawny  or  yellowish  colour,  with  smooth  surface  and  a  tough  and  elastic  feel. 
On  section  the  same  tawny  colour  is  seen,  the  acini  are  indistinct  or 
cannot  be  distinguished  ;  there  may  be  numerous  whitish  points  seen,  the 
so-called  miliary  gummata.  Microscopically  there  is  a  diffuse  infiltration 
of  small  cells  in  the  connective  tissue  between  the  lobules  and  surrounding 
the  portal  system,  and  also  thickening  of  the  arteries.  The  small  gummata 
consist  of  small  round  cells,  connected  with  the  smaller  branches  of  the 
portal  vein  or  biliary  capillaries  (Birch-Hirschfeld).  Embryonic  tissue  and 
excessive  amount  of  connective  tissue  are  usually  seen  in  a  later  stage. 

In  less  advanced  cases  there  may  be  no  marked  enlargement  of  the 
liver,  or  no  very  characteristic  appearances  to  the  naked  eye,  but  micro- 
scopically commencing  interstitial  hepatitis  may  be  found. 

The  following  case  may  be  taken  as  a  typical  illustration  : 

E.  B.,  ten  weeks  old,  was  admitted  to  hospital  January  1899.  An  older  brother 
suffers  from  syphilitic  brain  diseases  (general  paralysis  and  dementia).  The  infant  was 
born  healthy,  but  recently  it  had  suffered  from  coryza,  rash,  and  enlarged  abdomen.  On 
admission  he  was  well  nourished,  there  was  marked  coryza,  somewhat  hoarse  cry,  coppery 
scaly  rash  round  mouth,  remains  of  an  erythema  about  buttocks,  abdomen  distended  and 
tympanitic,  the  veins  on  surface  enlarged,  edge  of  liver  felt  reaching  nearly  to  umbilicus, 


Tubet'culosis  of  the  Liver  189 

spleen  much  enlarged.  The  infant  died  shortly  after  admission,  being  slightly  jaundiced 
before  death.  Post-mortem. — Brain  healthy,  lungs  slight  hypostatic  pneumonia  with  some 
minute  haemorrhages,  heart  normal,  abdomen  contains  about  an  ounce  of  yellow  cloudy 
fluid,  a  few  flakes  of  lymph  in  fissure  of  liver  and  on  intestines.  Liver  enlarged  i2|  oz. , 
yellow  tawny  colour,  surface  smooth,  firm,  tough,  and  elastic  in  consistence.  Cuts  with  a 
creaking  noise  ;  on  the  cut  surface,  which  is  of  a  dirty  yellow  colour,  in  places  the  lobules 
are  indistinguishable ;  in  other  places,  where  the  colour  is  more  reddish,  their  outline  is 
faintly  visible.  A  few  whitish  pin-head  points  seen  in  parts.  No  strands  of  connective 
tissue  visible,  no  large  gummata.  Spleen,  2^  oz.,  enlarged,  firm,  purple-red,  flakes  of 
l)'mph  on  surface.  Microscopically  there  was  infiltration  of  small  cells  surrounding  the 
portal  capillaries  and  between  the  acini  of  the  liver. 

In  older  children  gummata  and  cicatrices  are  found  at  times  on  the 
surface  of  the  hver  ;  with  this  there  may  be  more  or  less  cirrhosis,  giving  rise 
to  portal  obstruction  and  ascites.     See  p.  187. 

Fatty  Iiiver 

The  liver  becomes'  enlarged  from  being  infiltrated  with  fat  in  several 
different  diseases  during  infancy  and  early  childhood.  It  is  common  to  find 
children  who  are  fat,  pale,  and  rickety,  with  large  livers,  the  edge  of  the 
right  lobe  reaching  nearly  into  the  iliac  fossa  and  the  left  to  the  umbilicus. 
If  an  opportunity  occurs  {qx-Sl post-mortem  examination,  such  livers  are  found 
to  be  pale  and  greasy,  the  lobules  being  indistinct,  and  the  cells  are  seen 
microscopically  to  be  loaded  with  fat.  Such  children  are  usually  anaemic, 
have  large  distended  abdomens,  coated  tongues,  pasty  stools,  and  suffer  from 
chronic  indigestion.  Under  a  careful  dietary,  small  doses  of  mercurials  and 
salines,  such  as  Carlsbad  or  Rubinat  water,  improvement  gradually  takes 
place  and  the  liver  diminishes  in  size. 

Tuberculosis  of  the  Kiver 

Although  it  is  exceedingly  common  to  find  tubercles  in  the  liver  in  children 
dying  of  general  tuberculosis,  it  is  exceedingly  rare  for  these  tubercles  to  have 
given  any  indication  of  their  presence  during  life.  Tubercular  disease  of  the 
liver  generally  takes  the  form  either  of  grey  miliary  tubercles  scattered  through 
the  organ  and  on  the  surface,  or  of  cheesy  nodules,  rarely  larger  than  peas  or 
at  the  most  small  marbles,  which  appear  to  have  a  special  preference  for  the 
neighbourhood  of  the  bile  ducts.  These  caseous  masses  may  be  found  bile- 
stained  on  section,  and  small  cysts  formed  of  dilated  bile  ducts  filled  with 
inspissated  bile  may  be  found  which  have  been  caused  by  compression  of  the 
ducts.  Jaundice  is  rarely  produced  unless  there  are  enlarged  caseous  glands 
in  the  transverse  fissure  compressing  the  common  duct.  In  very  rare  instances 
caseous  masses  appear  to  form  in  the  liver,  resembling  the  caseous  masses 
seen  in  the  brain :  these  may  cause  enlargement  of  the  liver  and  gradually 
soften  down  into  a  chronic  abscess.  We  have  seen  only  one  case  of  this 
kind.     The  history  was  as  follows  : 

Chi-onic  Tuberculosis.  Hepatic  Abscess. — Boy,  aged  14  years,  father  and  mother 
dead;  never  been  out  of  England;  admitted  December  21,  1880;  recently  had  pain 
in  right  side  and  cough  ;  an  anasmic  boy  ;  yellowish  conjunctiva ;  pain  and  tenderness 
about  hepatic  region  ;    dulness  in   right    nipple   line  to  fifth  rib,  and   two  inch'es  below 


I  go  Diseases  of  the  Liver 

ribs.  Temperature,  99°-io2°.  January  13. — Slight  albumen  in  urine ;  liver  is  larger,  is 
tender  to  the  touch  and  on  percussion  ;  fine  rales  at  base  of  right  lung.  Temperature, 
Qeo_j-Q^o_  20th. — Liver  excessively  tender,  hepatic  region  bulging  ;  left  lobe  halfway  to 
umbilicus  ;  dulness  at  base  of  right  lung  to  angle  of  scapula  ;  explored  left  lobe  of  liver 
with  s)a-inge,  only  obtained  blood  ;  albumen  in  urine  ;  is  wasted.  21st. — Fluctuation  felt 
in  liver  ;  aspiration — this  time  obtained  an  ounce  or  two  of  thick  pus.  26th. — Fluctuation 
decidedly  felt ;  opened  antiseptically,  8  oz.  of  thick  glairy  pus,  mixed  with  blood  and 
bile  ;  tube  inserted,  followed  during  evening  by  large  discharge  of  pus.  28th. — Has 
been  very  weak,  vomiting  ;  left  leg  very  cedematous  for  a  day  or  two,  now  dark  blue  as  if 
becoming  gangrenous  ;  sudden  death. 

Post-mortem. — Body  emaciated  ;  pus  swelling  up  from  fistulous  opening  ;  left  leg  much 
swollen  ;  some  fluid  in  pericardium.  Heart  normal.  Right  lung  adherent  to  diaphragm 
by  lymph  and  fibrous  tissue  ;  no  pneumonia  ;  the  diaphragm  abnormally  raised  by  the 
enlarged  liver  below,  and  is  adherent  to  it  by  recent  lymph  ;  the  liver  has  been  punctured 
in  the  left  lobe  near  its  junction  with  the  right  on  its  upper  and  anterior  surface.  The 
fistulous  opening  enters  a  very  irregular  cavity  containing  pus  :  this  cavity  contains  semi- 
solid cheesy  material  and  irregular  fibrous  trabeculae,  which  give  it  a  worm-eaten  appear- 
ance ;  posteriorly  in  the  right  lobe  is  a  cheesy  mass,  size  of  an  orange,  beginning  to 
become  worm-eaten,  and  containing  a  little  pus  ;  a  few  other  irregular  cavities  joining 
together :  no  lardaceous  change.  Spleen  enlarged,  lardaceous.  Intestines  matted 
together  by  old  adhesions,  the  mesentery  containing  cretaceous  masses  (old  peritonitis 
from  suppurating  glands)  ;  contains  cicatrices  of  old  (tubercular)  ulcers  ;  no  recent  ulcera- 
tion. Mesenteric  glands  in  places  cretaceous.  Left  external  iliac  vein,  ante-mortem 
clot ;  kidneys  congested,  not  lardaceous  ;  lungs,  old  scars  at  apices  ;  pulmonary  artery 
contains  a/ite-mortem  clot ;  embolism. 

Hepatic  Abscess 

Children  occasionally  suffer  from  multiple  abscesses,  the  result  of  the 
absorption  of  some  septic  material  from  the  region  of  the  portal  vein,  or  from 
some  abscess  in  the  immediate  neighbourhood.  Thus  in  one  case  under  our 
care  multiple  abscesses  in  the  liver  were  evidently  secondary  to  an  ulcer  in 
the  csecal  appendix  caused  by  a  pin  which  had  been  swallowed.  In  a  second 
case  there  was  a  large  hepatic  abscess  communicating  through  the  diaphragm 
with  an  empyema  in  the  right  pleural  cavity  ;  and  in  a  case  of  Dr.  Hutton's 
hepatic  abscesses  were  due  to  the  contiguity  of  the  liver  with  suppurating 
retro-peritoneal  glands.  In  some  cases  which  have  been  recorded  abscesses 
in  the  liver  were  secondary  to  typhoid  ulcers,  and  in  others  to  the  irritation 
of  worms  which  had  penetrated  into  the  bile  ducts.  The  symptoms  consist 
in  enlargement  of  the  liver,  extreme  tenderness,  and  intermittent  fever.  The 
prognosis  is  bad.     If  pus  is  found,  it  should  be  evacuated  antiseptically. 

Hydatids 

Hydatid  cysts  in  the  liver  are  not  uncommon  during  later  childhood,  but 
are  decidedly  rare  before  five  or  six  years  of  age.  If  the  cyst  is  of  any  size  and 
situated  in  either  lobe  so  as  to  come  in  contact  with  the  abdominal  wall,  it 
will  form  a  smooth,  rounded  swelling  continuous  with  the  liver,  neither  pain- 
ful nor  tender,  elastic  to  the  touch,  or  actually  fluctuating.  Diagnosis  under 
such  circumstances  is  easy,  especially  if  the  tumour  is  tapped  or  aspirated, 
the  fluid  withdrawn  being  of  low  specific  gravity,  non-albuminous,  and  con- 
taining some  of  the  scolices  or  pieces  of  cyst  wall.  If  the  cyst  occupy  the 
posterior  part  of  the  right  lobe,  it  may  push  the  diaphragm  upwards  and  dis- 


Tumours  of  the  Liver  19 1 

charge  into  the  king  or  pleural  cavity  ;  occasionally  the  cyst  suppurates — in 
this  case  there  are  hectic  fever,  pain,  and  the  symptoms  of  an  abscess. 

Tj'eatmetit. — Aspiration  of  the  contents  of  the  cyst  may  be  sufficient  ; 
the  latter  collapses  and  the  hydatid  may  be  destroyed.  The  operation  may 
have  to  be  repeated,  as  the  cyst  may  fill  up  with  serum.  If  suppuration 
occurs  incision  is  recjuired,  and  in  all  cases  it  is  safer  and  better  to  open  the 
abdomen,  secure  the  cyst  to  the  abdominal  wall,  and  drain  the  cavity  with- 
out any  previous  aspiration,  even  if  suppuration  has  not  taken  place. 

In  a  case  under  our  care,  a  girl  of  twelve  years  who  had  a  large  hydatid 
of  the  liver,  the  cyst  was  aspirated  and  the  girl  left  the  hospital  apparently 
cured  ;  eighteen  months  after  she  was  readmitted  suffering  from  whatappeared 
to  be  an  empyema  of  the  right  side.  It  proved  to  be  a  suppurating  hydatid 
cyst  of  the  lung  ;  this  was  drained,  and  she  finally  made  a  good  recovery. 

Tumours  of  the  Skiver 

New  growths  originating  in  the  liver  during  childhood  are  among  the 
greatest  rarities,  though  cases  of  carcinoma,  sarcoma,  adenoma,  and  cavernous 
tumours  have  been  described.  An  interesting  case  of  lymphadenoma  of  the 
liver,  the  only  one  which  we  have  met  with,  was  admitted  to  the  Children's 
Hospital,  under  Dr.  Humphreys  (now  of  Torquay),  in  1878. 

A  boy  aged  14  years  suffered,  for  a  month  before  coming  under  notice,  with  pain  in 
the  right  hypochonch^iac  region  and  wasting  ;  he  noticed  a  swelling  in  the  same  region 
about  two  weeks  before  admission.  When  first  admitted  he  was  pale  and  sallow,  but  not 
jaundiced,  the  liver  was  enlarged',  the  edge  reaching  nearly  to  the  umbilicus  ;  there  was  a 
large  bossy  swelling  situated  between  the  right  costal  arch  and  the  umbilicus  ;  the  super- 
ficial abdominal  veins  were  enlarged  and  tortuous.  Aspiration  of  the  tumour  yielded 
nothing  but  blood.  He  wasted,  there  was  a  hectic  temperature  (98°-io2°),  and  the 
peritoneum  and  right  pleura  became  distended  with  fluid.  He  died  seven  weeks  after 
admission,  having  had  symptoms  for  three  months.  At  the  post-mortem  the  abdominal 
cavity  contained  much  fluid,  the  right  lobe  of  the  liver  was  much  enlarged  and  contained 
a  hemispherical  mass,  which  on  section  had  the  appearance  and  consistence  of  brain 
tissue  ;  there  were  some  haemorrhages  into  its  substance,  and  fibrous  bands  passed  through 
it.  It  was  surrounded  by  a  broad  zone  of  compressed  liver  tissue.  There  was  a  mass  of 
enlarged  glands  at  the  fissure.  The  right  pleura  was  full  of  fluid.  Microscopically  the 
new  growth  resembled  the  structure  of  lymphatic  glands.  In  this  case  it  was  not  easy  to 
decide  where  the  growth  commenced,  but,  as  in  the  analogous  case  of  lymphadenomata 
of  the  kidney,  there  is  a  strong  probability  that  it  began  in  the  lymph  glands  of  the  fissure 
and  grew  into  and  compressed  the  liver  substance. 


192  Diseases  of  Nutrition 


CHAPTER  XI 

INFANTILE   SCURVY 

Infantile  Scurvy  is  characterised  by  tenderness  of  the  bones,  hsemor- 
rhagic  stomatitis,  blood  efifusions,  purpura,  and  a  tendency  to  bleed  from 
various  organs. 

Dr.  W.  B.  Cheadle  was  the  first  to  point  out  that  this  condition  was  due 
to  scurvy,  and  to  show  the  curative  effects  of  orange  juice  and  fresh  food  ;  and 
Dr.  T.  Barlow  has  added  largely  to  our  knowledge  of  the  subject  by  his 
clinical  observations  2s\d.  post-mortem  examinations. 

Infants  of  under  six  months  rarely  suffer  from  scurvy  even  though  fed  on 
improper  food,  and  children  of  over  two  years  of  age  are  not  often  affected, 
probaloly  because  it  is  rare  for  them  to  be  fed  exclusively  on  a  diet  from 
which  fresh  food  is  excluded.  The  commonest  time  of  life  is  between  the 
ages  of  six  months  and  two  years,  especially  from  the  eighth  to  the  tenth 
month. 

The  cause  of  infantile  scurvy  is  undoubtedly  improper  feeding,  though 
other  causes  may  be  contributory.  An  infant  has  suffered  from  dyspepsia 
during  the  earlier  months  of  its  life,  it  has  been  unable  to  digest  diluted 
fresh  milk,  one  of  the  dried  milk  foods  or  condensed  milk  has  been  substi- 
tuted, whereupon  the  dyspepsia  has  improved,  the  infant  has  apparently 
flourished,  until  it  was  seven  or  eight  months  old  ;  then  it  has  begun  to 
suffer  with  pain  and  tenderness  in  its  legs,  or  has  shown  other  signs  of 
commencing  scurvy.  While  perhaps  in  this  country  at  least  tinned  or  pre- 
served foods  of  the  dried  or  condensed  sort  are  responsible  for  more  infantile 
scurvy  than  any  other  foods,  yet  these  foods  are  not  alone  in  producing 
these  symptoms.  The  continuous  use  of  peptonised  or  pancreatised  foods 
whether  made  with  preserved  or  fresh  milk  will  undoubtedly  produce  scur\y  ; 
and  so  also  will  malted  starch  or  starchy  foods  though  made  up  with  fresh 
milk.  The  tendency  in  the  use  of  these  foods  is  to  give  too  much  of  the 
food  and  too  little  fresh  milk.  Milk  foods  sold  in  bottles,  known  as  '  human- 
ised,' and  which  have  been  over-heated  in  order  to  make  them  keep,  are  also 
responsible  for  a  large  number  of  cases  of  infantile  scurvy.  Scurvy  mostly 
of  a  mild  type  is  seen  also  in  infants  fed  on  freshly  sterilised  milk,  milk  and 
barley  water,  and  also  on  raw  milk,  though  this  is  not  common.  Mild  scurvy 
may  also  be  seen  at  times  in  infants  taking  their  mothers'  milk.  It  is  not 
uncommon  to  find  among  the  poorer  classes  of  a  city,  infants  often  to  four- 
teen months  being  nursed  exclusively  on  their  mothers'  milk,  and  to  find  them 
very  anasmic,  with  a  zone  of  congestion  around  those  teeth  which  have  been 


Infantile  Scurvy  193 

cut,  and  an  ill-defined  tenderness  about  their  limbs.  Such  cases  improve  at 
once  when  given  fresh  cow's  milk  and  orange  juice. 

In  a  considerable  proportion  of  cases  the  infants  who  suffer  from  scurvy 
have  been  difficult  to  feed,  and  have  suffered  from  various  forms  of  dyspepsia, 
vomiting,  diarrhoea,  pain  and  discomfort  in  the  bowels.  In  some  there  is  a 
history  of  bronchitis  which  in  many  cases  seems  to  affect  the  digestion.  In 
a  minorityof  cases — at  least  this  has  been  our  experience — the  infants  who  de- 
velop scurvy  have  been  tolerably  well  according  to  their  friends'  account, 
but  an  examination  is  very  likely  to  show  that  they  are  ancemic,  and  very  often 
show  signs  of  rickets. 

While  it  is  certain  that  some  dietetic  error  is  the  chief  factor  in  producing 
scurvy,  there  is  much  about  its  etiology  which  is  not  perfectly  plain.  It  is 
certain  that  the  worst  forms  will  be  found  to  have  had  either  preserved  milk 
or  peptonised  food,  and  moreover  they  improve  at  once  if  given  orange  juice 
or  fresh  milk  in  sufficient  quantities.  But,  on  the  other  hand,  it  is  certain  that 
in  some  instances  infants  of  eight  or  nine  months  old  who  have  been  taking 
30  to  40  oz.  of  milk  a  day  have  suffered  from  scurvy,  and  we  have  known  infants 
of  the  same  age  given  dried  milk  food  for  months  without  developing  scurvy 
though  they  have  suffered  from  rickets.  Several  times  we  have  seen  the 
early  symptoms  of  scurvy  arise  in  infants  in  hospital  who  were  wasted  and 
feeble,  and  were  taking  a  weaker  food  than  a  healthy  infant  of  the  same  age 
should  have  been  doing  on  account  of  their  weakly  digestions,  and  this  in 
spite  of  their  diet  including  beef  tea  made  with  vegetables.  In  another  case, 
that  of  a  wasted  infant  of  9  months  taking  a  mixture  of  cream  diluted  with 
milk-sugar  water,  the  hmbs  became  tender  and  the  gums  red,  but  it  improved 
at  once  when  whey  was  used  to  dilute  the  cream,  the  amount  of  cream  con- 
tinuing the  same. 

Scurvy. — Jim  C. ,  one  year  old,  admitted  to  hospital  January  13,  weight  10  lb.  40Z.,  had 
suffered  much  from  diarrhcea  and  vomiting,  was  wasted  and  his  subcutaneous  tissues  were 
cedematous  ;  he  was  given  a  peptonised  cream  mixture.  January  26  he  was  given  12  oz. 
of  cream  mixture  made  freshly  and  pasteurised,  containing  fat  2>'7h  P^r  cent.,  proteids 
175  per  cent.,  and  sugar  6  per  cent.  ;  also  12  oz.  of  beef  tea  made  with  vegetables. 
February  2  he  had  some  slight  broncho-pneumonia,  temperature  98°-io3°  F.  for  a  few 
days.  February  9  it  was  noted  the  gums  were  hasmorrhagic  around  some  teeth  that  were 
being  cut.  He  was  given  three  teaspoonfuls  of  orange  juice  daily,  his  food  remaining  the 
same  ;  in  four  or  five  days  his  gums  were  healthy  ;  his  temperature  was  intermittent  for 
some  days  after. 

In  another  case,  an  infant  of  nine  months,  weighing  9  lb.  6  oz.  when  admitted,  was 
given  25  oz.  of  cream  mixture  and  beef  tea  with  some  potato  added  ;  the  gums  became 
hasmorrhagic,  and  the  right  femur  tender  and  swollen.  The  haemorrhage  disappeared  in  a 
week  after  orange  juice  was  given,  and  without  change  of  diet. 

It  would  certainly  seem  that  in  the  majority  of  cases,  at  least,  infantile 
scurvy  was  caused  by  an  insufficient  amount  or  absence  of  an  element 
which  is  lacking  in  preserved  foods  and  present  in  fresh  milk  and  also 
in  orange  juice  ;  that  occasionally  this  element  is  present  in  insufficient 
quantities  in  fresh  cow's  milk  or  in  human  milk  ;  that  absence  of  fresh  air, 
Hfe  in  stuffy  bedrooms,  depressing  diseases  as  bronchitis  and  diarrhoea, 
were  contributory  causes. 

It  is  interesting  to  note  that  so  acute  and  experienced  an  observer  as 

O 


194  Infantile  Scurvy 

Dr.  Nansen  looks  upon  adult  scurvy  as  a  disease  not  due  to  the  absence  of 
a  certain  element  in  the  food,  but  rather  to  the  presence  of  ptomaines  in 
badly  preserved  milk,  salt  beef,  or  other  preserved  foods.  He  believes  that 
if  the  preserved  foods  taken  on  a  voyage  are  most  carefully  sterilised,  so 
that  they  keep  well,  if  regular  exercise  and  plenty  of  fresh  air  are  taken  by 
the  crew,  and  no  intemperance  indulged  in,  there  will  be  no  scurvy,  and 
orange  and  lime  juice  are  unnecessary.  The  symptoms  of  scurvy  are  un- 
doubtedly very  suggestive  of  ptomaine  poisoning,  but  further  light  is  needed. 

Infantile  scurvy  is  undoubtedly  most  common  among  the  infants  of  the 
comfortably  circumstanced  classes,  who  are  able  to  afford  proprietary  foods, 
but  it  is  by  no  means  uncommon  among  the  infants  who  attend  the  out- 
patient department  of  the  Manchester  Children's  Hospital  ;  these  are  among 
the  poorest  in  the  city,  and  are  fed  largely  on  boiled  bread,  supplemented 
perhaps  by  breast  milk.  Sweetened  condensed  milk  is  also  a  favourite  food 
among  the  working-class  population. 

Symp/oins. — One  of  the  earliest  and  most  chai'acteristic  symptoms  is 
pain,  tenderness  and  immobility  in  one  of  the  lower  limbs.  With  this 
there  is  usually  some  haemorrhagic  swelling  round  a  tooth  which  has 
recently  been  cut  or  which  is  about  to  be  cut.  The  pain  and  tenderness  in  one 
of  the  lower  limbs  may  be  difficult  to  localise  if  only  slight,  but  the  infant 
draws  up  its  leg  and  cries  when  it  is  washed  or  disturbed,  as  in  taking  it  up 
and  carrying  it  about.  It  is  perhaps  thought  to  have  rheumatism,  or  early 
disease  of  the  hip  is  suspected.  If  the  child  has  been  walking  or  crawling, 
it  will  probably  refuse  to  put  its  foot  to  the  ground.  When  the  disease  is 
more  marked  the  infant  cries  or  screams  as  if  in  acute  pain  when  the  limb 
is  handled,  and  indeed  cries  if  it  sees  anyone  coming  near  its  cot  with  the 
intent  of  disturbing  it.  The  hip,  as  we  have  said,  may  be  drawn  up  and  held 
rigidly,  or  it  may  hang  down  or  lie  motionless  like  a  limb  which  is  paralysed. 
In  some  cases  it  has  happened  that  a  diagnosis  of  infantile  paralysis  has 
been  made.  Whenever  the  above  symptoms  are  observed  in  an  infant  of 
eight  or  nine  months  or  more,  scurvy  should  be  suspected  and  the  gums 
carefully  examined.  Appropriate  dietetic  treatment  should  at  once  be 
commenced.  In  more  marked  cases  there  will  be  a  more  or  less  distinct 
swelling  in  connection  with  some  bone,  usually  the  femur  or  tibia,  or  one  or 
both  legs  may  be  swollen  with  the  skin  tense  and  shiny.  There  is  usually 
marked  weakness  of  the  muscles  of  the  back,  so  that  the  infant  no  longer 
attempts  to  sit  up  or  hold  up  its  head,  but  lies  helpless  in  its  cot  and  resents 
with  cries  any  attempt  to  examine  it.  It  is  good  enough  if  not  disturbed, 
but  cannot  bear  to  be  interfered  with  in  any  way.  Swellings  may  be  noted 
in  connection  with  the  bones  of  the  upper  extremity,  more  especially  the 
humerus,  or  the  ileum,  scapula,  or  skull.  Various  haemorrhages  are  apt  to 
take  place,  the  commonest  being  from  the  kidneys.  The  urine  discolours 
the  napkins  of  a  reddish  brown  colour,  or  a  deposit  of  red-coloured 
sediment  is  noted  in  the  chamber  vessel,  and  if  the  urine  is  collected  and 
examined  the  reactions  for  albumen  and  blood  will  be  found.  Occasionally 
there  is  albumen  and  no  blood.  The  urine  is  not  smoky  or  dark  as  in 
nephritis.  In  some  cases  the  hsematuria  and  stomatitis  are  the  only 
symptoms  present,  or  they  may  be  the  earliest  symptoms.  In  one  case 
coming  under  our  notice,  a   stone  in  the  bladder  had  been  suspected  and 


Infantile  Scurvy  195 

the  infant  sounded  for  stone.  There  may  be  oozing  of  blood  from  other 
organs,  from  the  bowels,  from  the  nasal  mucous  membranes,  from  fissures 
in  the  anus  or  cracks  in  the  lips.  An  orbital  haemorrhage  is  not  uncommon, 
especially  if  the  infant  has  a  bad  cough  at  the  time  and  strains  itself  When 
this  happens  the  eye  is  pressed  forwards  :  the  eyehd  is  often  oedematous. 
giving  the  infant  a  peculiar  appearance.  In  bad  cases  purple  discolourations 
of  the  skin  from  subcutaneous  bleedings  are  common,  bruise  marks  being 
present  round  the  eyes  and  in  various  places  about  the  trunk  and  limbs.  A 
ha:morrhagic  condition  may  be  noted  beneath  the  finger  nails  near  their 
roots.  The  gums  may  be  much  swollen,  may  bleed  easily  and  be  very  foul. 
Separation  of  an  epiphysis  and  fractures  of  the  shaft  of  one  of  the  bones 
take  place  in  some  cases.  The  former  is  the  more  common,  especially 
separation  of  the  lower  end  of  the  femur.  We  have  only  seen  one  case  of 
fracture  of  a  shaft,  and  verified  it  by  post-mortem  examination.  This  was 
the  case  of  a  child  of  fourteen  months  of  age,  illegitimate  and  badly  cared 
for  ;  it  had  been  put  out  to  nurse,  and  fed  on  bread  and  milk,  though  it  was  a 
question  how  much  milk  she  had  really  had.  Both  humeri  were  fractured 
near  the  junction  of  the  upper  two  thirds  with  the  lower  third.  The  child 
was  very  anemic  and  rickety,  and  there  was  a  blood  swelling  over  the  femur. 
At  the  post-mortem  it  was  found  that  the  fractures  were  oblique  and  had 
evidently  been  done  some  time  before  death,  presumably  by  holding  the 
child  by  its  arms  and  shaking  it  for  crying.  The  periosteum  had  been 
stripped  off  by  the  effused  blood.     The  bones  were  markedly  rickety. 

In  the  majority  of  cases  when  the  disease  is  well  mai^ked  the  infant  is 
anaemic  and  shows  signs  of  rickety  bones.  The  tip  of  the  sternum  and 
sides  of  the  chest  wall  are  drawn  in  during  inspiration,  the  ribs  are  beaded 
and  the  epiphyses  of  the  long  bones  enlarged.  Not  infrequently  there  may 
be  marked  signs  of  rickets  in  an  infant  with  anaemia,  and  slight  tenderness 
of  bones.  In  some  cases  of  scurvy  the  temperature  is  raised  a  degree  or 
two,  presumably  as  the  result  of  some  periosteal  inflammation  near  the  seat 
of  the  blood  swellings. 

The  prognosis  is  good  if  treatment  is  commenced  before  the  infant  has 
become  too  feeble  and  exhausted.  In  fatal  cases  death  has  sometimes 
supervened  suddenly  from  cardiac  failure  or  a  haemorrhage  on  the  surface  of 
the  brain. 

Scurvy  is  apt  to  run  a  chronic  course  in  the  absence  of  treatment 
directed  to  the  cause,  whereas  it  usually  is  quickly  cured  if  the  diet  is  changed 
in  the  direction  of  giving  fresh  food  in  some  form. 

The  following  case  illustrates  some  of  the  above  remarks  : 

Scurvy. — The  patient  was  an  infant  (a  girl)  aged  seven  months,  of  middle-class  parents 
(patient  of  Dr.  Alfred  Brown).  We  were  given  the  following  history  :  Healthy  born,  mother 
unable  to  nurse  it  ;  it  was  consequently  given  Allen  and  Hanbury's  No.  i  food,  which  con- 
sists of  desiccated  milk  ;  at  three  months  of  age  it  was  given  their  No.  2  food,  which  con- 
sists of  desiccated  milk  and  maltose  ;  at  five  months  of  age  it  was  given  the  No.  3  food, 
which  consists  of  a  malted  food,  to  be  made  up  with  fresh  milk  instead  of  with  water,  as 
are  the  No.  i  and  No.  2  ;  but  the  mother,  thinking  that  fresh  milk  would  not  suit,  made 
up  the  No  3  food  with  No.  2  food.  Thus  the  infant  had  had  for  seven  months  no  fresh 
food  at  all,  but  dried  milk  and  maltose  made  into  an  emulsion  with  water.  The  mother 
stated  that  the  infant  had  thriven  well,  and  was  always  looked  upon  as  a  prize  baby,  and 
no  doubt  her  photograph  would  have  formed  an  excellent  testimonial  for  the  food  supply. 

o  2 


196  Infantile  Scurvy 

For  two  or  three  weeks  past  she  has  had  a  bad  cough.  Two  weeks  before  our  visit,  the 
nurse  noticed  the  left  eyeball  was  very  prominent ;  this  appears  to  have  come  on  suddenl)', 
and  so  prominent  was  it  that  the  nurse  said  she  fully  expected  '  it  would  drop  out. '  This 
was  attributed  to  a  slight  blow  the  infant  had  had  on  the  eye  from  a  '  teat,'  or  '  comforter,' 
tied  at  the  end  of  a  string.  The  eye  has  continued  prominent  ever  since.  She  had  had 
several  'bad  faints.'  On  examination,  we  found  the  baby  w-as  large,  fat,  and  pale;  there 
was  a  temperature  of  101°  F.  She  was  drows}^  but  was  readily  roused.  The  left  eyeball 
was  very  prominent,  and  while  the  right  eyelid  closed  naturally,  the  left  ball  was  in  part 
exposed,  as  the  eyelids  when  closed  would  not  meet.  The  eyelids  were  not  puffy,  there 
were  no  ecchymoses  either  on  the  eyeball  or  elsewhere.  The  ribs  were  beaded,  but  there 
was  no  tenderness  about  the  limbs  or  elsewhere.  She  had  some  bronchial  catarrh,  and  a 
persistent  cough.  No  teeth  were  cut ;  the  gums  were  normal.  The  nurse  stated  the  urine 
stained  the  napkins  a  brownish  colour,  but  we  could  not  substantiate  this.  She  rapidly 
improved  when  gi^'en  fresh  milk  and  orange  juice. 

Treatment. — In  order  to  prevent  scurvy,  an  infant  if  not  fed  at  the  breast 
should  have  fresh  milk  from  healthy  cows  in  quantities  sufficient  to  supply  its 
necessities.  If  in  consequence  of  indigestion  it  is  necessary  to  lessen  the 
quantity  of  food  which  it  takes,  care  should  be  taken  to  bring  the  quantity 
again  up  to  the  normal  as  soon  as  possible.  If  this  cannot  be  done  the 
infant  should  be  carefully  watched  for  any  symptoms  of  scurvy  such  as 
tenderness  of  the  bones  or  hsemorrhagic  stomatitis.  There  is  no  necessity 
to  give  raw  milk  ;  it  must  be  rare  for  children  taking  a  full  quantity  of  freshly 
sterilised  or  boiled  milk  to  develop  scurvy.  The  risk  is  far  greater  in  using 
sterilised  milk  which  has  been  heated  to  a  high  temperature  and  kept  in 
stock  for  some  months  before  being  used.  All  dried  milk  foods  or  peptonised 
foods  should  be  used  as  temporary  resorts  only,  or  should  not  constitute  the 
sole  food  of  the  infant,  and  this  is  especially  dangerous  after  the  infant  has 
passed  six  months  of  age.  If  any  symptoms  of  scurvy  appear  \  oz.  to  i  oz.  of 
fresh  orange  juice  should  be  given  daily  and  30  to  40  oz.  daily  of  fresh  milk 
according  to  the  child's  age.  If  it  is  necessary  to  dilute  the  milk,  whey 
should  be  used  in  preference  to  barley  water  or  starchy  fluids.  If  the  child 
is  over  a  year  old  and  its  digestive  powers  are  good,  beef  tea  with  vegetables, 
potato  broth  or  an  ^^^  may  be  added  to  its  diet.  All  forms  of  peptonised  or 
malted  foods  should  be  avoided,  or  excess  of  starchy  foods,  also  all  meat 
extracts,  manufactured  meat  juices,  and  all  proprietary  and  patent  foods. 
Fresh  air  and  sunlight  are  of  great  service.  The  most  difficult  cases  are  those 
in  which  there  is  chronic  indigestion  as  well  as  scurvy. 


197 


CHAPTER    XII 

GENERAL    DISEASES 

Rickets 

Rickets  is  a  disease  that  usually  makes  its  appearance  during  the  first  two 
or  three  years  of  life  ;  it  is  characterised  by  chronic  indigestion,  deformities 
of  the  bones,  weakness  of  the  muscles  and  ligaments,  and  various  peculiar 
nervous  disorders.  Dentition  is  retarded  ;  there  is  frequently  enlargement 
of  the  liver  and  spleen. 

The  commonest  time  for  rickets  to  manifest  itself  is  from  the  first  six 
months  to  the  end  of  the  second  year,  but  it  is  not  uncommonly  noted  during 
the  first  few  months  of  life,  and  in  rare  cases  infants  may  be  born  exhibiting 
undoubted  rickety  changes  in  their  bones.  During  the  first  year  or  two  of 
life,  even  in  health,  the  digestive  system  is  worked  to  its  utmost  capacity,  in 
order  that  it  may  be  able  to  supply  the  system  with  sufficient  nutrient  material, 
not  only  for  the  exigencies  of  daily  life,  but  also  for  the  rapid  building  up  of 
the  tissues  which  is  going  on  at  this  time  ;  an  impairment  of  the  digestive 
powers,  a  weakening  of  the  digestive  ferments,  or  food  inadequate  in  quantity 
or  of  an  improper  kind,  necessarily  means  that  the  tissues  fail  to  receive  the 
amount  of  nutriment  they  require.  This  failure  of  the  nutrient  powers  is  an  im- 
portant factor  in  bringing  about  the  changes  which  characterise  rickets.  That 
a  state  of 'mal-nutrition  does  not  always  produce  rickets  is  certain,  but  it  is 
certainly  true  that  it  often  does,  and,  moreover,  in  all  cases  of  rickets  of  any 
degree  of  severity  there  is  evidence  of  a  pre-existing  failure  of  the  digestive 
powers.  In  some  of  the  milder  forms  of  rickets,  when  the  ribs  are  seen  to 
be  beaded  and  the  bones  of  the  extremities  deformed,  without  any  of  the 
symptoms  which  mark  the  severer  grades,  the  child  may  be  fat  and  appa- 
rently healthy,  and  there  may  be  no  evidence  of  a  present  or  past  mal- 
nutrition ;  but  inquiry  will  generally  elicit  some  past  illness  or  subacute 
dyspepsia,  or  a  history  of  improper  feeding,  or  some  conditions  which  have 
tended  to  produce  a  mal-assimilation  or  imperfect  digestion  of  the  food. 
The  deformities  produced  by  rickets  may  continue  to  be  present  long  after 
the  acute  stage  has  passed  away. 

While  we  do  not  believe  that  it  has  been  satisfactorily  shown  that  a  ten- 
dency to  rickets  is  hereditary  in  the  same  sense  that  a  tendency  to  gout  is 
hereditary,  yet  we  are  far  from  denying  that  hereditary  influence  plays  some 
part  in  predisposing  to  rickets.  We  believe  that  if  either  father  or  mother, 
especially  the  latter,  is  weakly  from  any  cause,  their  children  will  be  more 
likely  to  suffer  from  rickets.     A  woman  does  much  manual  labour  during  her 


198  General  Diseases 

pregnancy,  more  than  her  strength  will  really  admit  of,  or  she  lives  under 
unhealthy  conditions  :  the  infant  is  weakly,  is  difficult  to  rear,  and  becomes 
rickety  ;  we  can  hardly  doubt  that  the  influence  of  the  mother's  health  has 
predisposed  to  rickets,  or  at  least  to  the  digestive  troubles  which  precede 
rickets.  We  feel  certain  that  weakly  or  premature  infants  may  become 
rickety,  even  though  the  greatest  pains  and  care  have  been  bestowed  on  their 
feeding  and  bringing  up.  The  fact  that  rickets  may  appear  during  intra- 
uterine life  and  the  infant  be  born  with  beaded  ribs  and  other  symptoms  of 
rickets,  shows  that  rickets  can  be  produced  apart  from  any  improper  feeding, 
and  suggests  that  the  influence  of  the  mother's  health  during  pregnancy  may 
be  an  important  factor  in  predisposing  to  the  disease.  The  influence  of 
the  mother's  health  in  producing  rickets  is  seen  in  large  famihes,  where 
the  later  children  born  are  apt  to  be  ricket}^  It  happens  also  at  times  that 
first-born  children  are  rickety,  especiahy  in  those  cases  where  the  mother  is 
very  young. 

Does  syphilis  in  the  parents  predispose  to  rickets  in  the  infant  ?  Parrot 
asserted  that  rickets  was  the  result  of  the  syphilitic  poison — that  the  latter 
when  worn  out  or  weakened  produced  rickets.  Very  few,  even  among  his 
own  countrymen,  have  accepted  his  views.  Among  the  foundlings  of  Paris 
and  other  large  cities  where  syphilis  is  a  common  disease,  it  may  be  difficult 
or  impossible  to  say  exactly  what  influence  syphilis  exerts  in  producing  rickets  ; 
in  country  districts,  where  syphilis  is  uncommon  and  rickets  common,  it  is 
clearly  seen  that  there  is  no  connection  between  the  two,  or  only  that  the 
syphihtic  poison  has  a  depressing  influence  on  the  system  and  so  predisposes 
to  rickets  as  it  appears  to  do  to  tuberculosis. 

Dietetic  hifluences. — It  has  been  stated  that  infants  nursed  at  the  breast  of 
a  healthy  mother  rarely  become  rickety,  we  may  say  never  suffer  from  severe 
rickets  :  while  infants  who  have  been  artificially  fed  from  the  first,  and  who 
have  suffered  much  from  dyspeptic  ailments,  are  nearly  always  affected. 
It  is  certain,  however,  that  over-lactation  is  a  cause  of  rickets.  Infants  who 
have  been  suckled  at  the  breast  for  over  ten  months  or  a  year  frequently 
suffer  from  rickets.  Infants  who  have  suffered  from  diarrhoea,  gastric  catarrh, 
bronchitis,  pneumonia,  and  especially  those  who  have  had  a  hard  struggle 
for  hfe,  very  frequently  become  rickety.  Infants  who  were  premature,  and 
who  have  been  reared  with  difficulty,  are  among  those  who  often  suffer. 
Infants  badly  fed,  and  those  who  from  ignorance  or  necessity  have  been 
deprived  of  fresh  milk  and  given  large  quantities  of  food  in  which  starch  has 
taken  the  place  of  fat,  are  exceedingly  likely  to  suffer  from  rickets.  That 
improper  feeding  plays  an  important  part  in  the  production  of  rickets  has 
been  shown  in  the  rearing  of  the  young  lions  at  the  Zoological  Gardens,  and 
in  the  feeding  of  puppies  and  other  animals  on  lean  meat.  These  animals 
developed  rickets,  but  improved  at  once  when  given  milk  and  pounded 
bones.'  The  same  thing  may  be  seen  again  and  again  among  our  dispensary 
patients  ;  a  marked  improvement  in  the  symptoms  following  their  admission 
to  hospital,  where  a  more  suitable  diet  is  given  than  the  one  which  they  have 
been  taking. 

Now,  while  there  cannot  be  a  doubt  that  infants  who  have  been  given 
large  quantities  of  sago,  sopped  bread,  arrowroot,  condensed  milk  of  a  poor 
1  See  Cheadle,  '  Rickets,'  Brit.  Med.  Assoc.  Meeting,  1888. 


Rickets  199 

quality,  or  one  or  more  of  the  much-advertised  patent  foods,  early  develop 
rickets,  yet  so  also  do  some  infants  who  have  been  brought  up  on  fresh  milk 
and  water,  milk  and  cream,  and  peptonised  milk.  The  food  may  have  been 
theoretically  correct  as  far  as  quality  goes,  the  child  may  have  been  well 
looked  after,  and  the  parents  or  friends  are  surprised  at  being  told  that  it 
has  developed  more  or  less  of  rickets.  But  children  who  thus  become 
rickety  though  brought  up  on  fresh  or  sterilised  milk  have  almost  certainly 
suffered  a  good  deal  from  gastric  or  intestinal  catarrh,  and  their  food  has 
failed  to  be  digested  and  assimilated.  It  is  no  uncommon  thing  to  find  a 
child  of  eight  or  nine  months,  markedly  rickety,  being  fed  with  far  more  milk 
than  it  can  possibly  digest,  passing  curd,  pasty  stools,  and  suffering  from 
flatulence  and  colic.  A  food  in  which  starch  or  sugar  has  replaced  fat,  or 
which  in  other  ways  differs  from  human  milk,  will  be  only  too  likely  to  give 
rise  to  rickets  ;  but  the  food  may  have  contained  fat  in  normal  quantities 
and  been  otherwise  suitable,  yet  if  the  child  suffers  from  chronic  dyspepsia, 
and  the  milk  food  has  undergone  excessive  lactic  or  butyric  fermentation  in 
the  alimentary  canal,  and  consequently  failed  to  nourish,  the  child  is  likely 
to  be  rickety,  and  it  may  suffer  laryngismus  and  convulsions.  It  seems  very 
probable  that  some  toxines,  the  result  of  indigestion,  which  have  been 
absorbed  into  the  blood,  are  the  immediate  causes  of  some  of  the  symptoms 
of  rickets. 

Hygienic  and  Climatic  Influences. — The  children  of  the  well-to-do  classes 
suffer  less  from  rickets  than  those  of  the  poor,  and  when  they  are  affected  it 
is  in  a  milder  degree  ;  the  same  may  be  said  of  country  children  as  com- 
pared with  the  denizens  of  the  slums  of  our  great  cities.  Rickets  is  more 
common  in  damp  cold  climates  than  in  warmer  ones.  From  these  facts  we 
gather  that  bad  ventilation,  and  absence  of  fresh  air  and  sunlight,  are  factors 
in  producing  rickets.  That  this  influence  is  exercised  through  the  digestive 
organs  is  very  probable. 

From  the  above  remarks  it  is  clear  that  we  believe  there  are  several 
factors  in  the  production  of  rickets.  Hereditary  weakness,  feebleness  of  the 
digestive  powers,  improper  food,  breathing  vitiated  air,  exposure  to  cold 
and  damp,  will  together,  in  some  instances  perhaps  singly,  produce  rickets. 
Rickets  abounds  wherever  the  lower  classes  of  the  population  are  crowded 
together  in  courts  and  slums,  where  the  mothers,  from  necessity  or  choice, 
are  unable  to  suckle  their  infants,  where  fresh  cow's  milk  is  dear  and  of 
poor  quality,  and  infant  life  is  exposed  to  the  various  bad  influences  which 
poverty  and  ignorance  are  certain  to  produce.  Rickets  is  a  rare  disease 
where  the  parents  are  strong  and  healthy,  the  mother  able  to  nurse  her 
infants,  while  taking  care  of  her  own  health  and  diet,  and  is  able  to  devote 
her  whole  time  to  the  care  and  nurture  of  her  offspring. 

Chemical  Theories. — The  older  authors  attributed  rickets  to  the  absence, 
or  diminished  quantities,  of  lime  salts  in  the  food,  but  ver}^  little  observation 
was  sufficient  to  disprove  this.  Others  (Seeman)  have  supposed  a  deficiency 
of  hydrochloric  acid  in  the  gastric  juice,  and  that  consequently  the  lime  salts, 
instead  of  entering  the  blood,  passed  through  the  alimentar)^  canal.  Some 
have  thought  there  was  a  deficiency  of  phosphoric  acid  or  phosphates  in  the 
food,  and  that  its  absence  from  the  blood  prevented  the  formation  of  bone. 
The  'acid  theory'  has  also  had  supporters,  who  supposed  there  was  an  excess 


200  General  Diseases 

of  lactic  acid  in  the  blood,  which  had  been  formed  from  the  decomposi- 
tion of  milk  in  the  stomach — the  presence  of  the  lactic  acid  dissolving  the 
lime  salts  of  the  bones  and  carrying  them  out  of  the  body  in  the  urine.  We 
confess  to  being  completely  sceptical  concerning  all  these  hypotheses,  and 
much  doubt  if  they  explain  anything  as  to  the  pathogenesis  of  rickets.  We 
certainly  think  that  an  amount  of  both  fat  and  proteids  in  the  food  below  the 
normal  may  be  one  factor  in  producing  rickets. 

Symptoms  and  Course. — The  premonitory  or  early  symptoms  of  rickets 
may  be  absent,  or  so  intermingled  with  those  of  dyspepsia  that  it  may  be  im- 
possible to  differentiate  them.  In  the  slighter  grades  of  rickets  the  first  and 
perhaps  the  only  signs  of  the  affection  are  slightly  beaded  ribs  and  enlarged 
epiphyses  at  the  lower  ends  of  the  radius  and  ulna.  In  the  more  severe  forms 
of  the  disease  the  early  symptoms  are  slight  fever,  the  infant  being  hot  and 
restless  during"  sleep  ;  abundant  perspiration,  more  especially  about  the  fore- 
head and  scalp,  may  then  be  noticed  ;  at  this  time  the  infant  may  suffer  from 
convulsions  and  not  infrequently  laryngismus.  His  bones  may  be  more  or  less 
tender,  so  that  he  cries  on  being  moved  or  danced  about  in  the  nurse's  arms, 
and  usually  some  beading  of  the  ribs  can  be  detected.  In  the  majority  of 
cases  the  abdomen  is  habitually  distended  with  wind,  and  there  is  mostly 
constipation,  though,  on  the  other  hand,  the  stools  may  be  loose  and  curdy. 
The  child  may  be  anaemic  and  the  spleen  may  be  felt  to  be  enlarged. 

As  time  goes  on  it  is  noted  that  there  is  a  delay  in  the  appearance  of  the 
teeth  ;  if  the  first  two  incisors  have  been  cut,  a  long  interval,  perhaps  many 
months,  elapses  before  the  appearance  of  the  others,  and  the  teeth  that  have 
been  cut  are  apt  to  become  carious,  from  a  deficiency  in  their  enamel.  The 
muscular  system  is  almost  certain  to  suffer,  the  child  cannot  sit  up  from  weak- 
ness of  the  lumbar  muscles,  and  the  spine  bows  out  from  laxity  of  the  liga- 
ments ;  the  infant  does  not  use  its  limbs  like  a  healthy  child,  making  no, 
or  poor,  attempts  at  crawling  ;  its  legs  are  weak,  it  cannot  bear  its  weight  on 
them  or  even  put  them  to  the  ground. 

Concurrently  with  many  of  these  phenomena,  marked  changes  are  noted 
in  the  bony  skeleton.  The  bones  may  be  tender  to  the  touch,  and  the  infant 
resent  being  jumped  about.  It  is  quite  possible,  however,  that  this  tender- 
ness is  produced  by  slight  hgemorrhages,  which  are  really  scorbutic.  Scurvy 
and  rickets  frequently  are  associated  together.  The  skull  early  shows  these 
changes,  though,  if  rickets  does  not  supervene  till  the  middle  or  end  of  the 
second  year,  the  bones  of  the  skull  may  escape.  There  is  a  marked 
exaggeration  of  the  frontal  and  parietal  eminences,  with  some  flattening  of 
the  upper  surface,  so  that  there  is  a  sort  of  table-land  at  the  vertex,  the  head 
assuming  a  more  or  less  quadrate  shape.  Sometimes  there  is  flattening  of 
the  occipital  bone  behind,  so  that  the  back  of  the  head  looks  as  if  pressed 
in.  In  severe  cases  there  are  broad  shallow  grooves  corresponding  with  the 
sagittal  and  coronal  sutures,  and  consequently  running  at  right  angles  with 
one  another.  The  fontanelles  are  widely  open  and  may  remain  so  long  after 
they  should  be  closing  up,  and  the  edges  of  the  bones  where  they  come 
together  to  form  the  sagittal,  coronal,  and  lambdoidal  sutures  are  thickened. 
Instead  of,  or  in  combination  with,  these  hypertrophic  changes  at  the 
eminences  and  edges  of  the  bones,  there  may  be  atrophy  or  thinning  of  the 
central   parts    of  the  occipital  or  parietal  bones,  which  has  been  termed 


Rickets 


201 


cranio-tabes.  These  weak  places  can  be  felt  by  gentle  pressure  exerted' 
with  the  finger  on  the  occipital  or  parietal  bones,  of  course  avoiding 
the  sutures,  the  bone  perhaps  bending  and  bowing  in  almost  like  parchment 
beneath  the  finger.  It  has  been  questioned  to  what  extent  cranio-tabes  is 
the  result  of  rickets,  as  it  is  present  at  times  in  undoubtedly  syphilitic 
children,  and  also  in  those  suffering  from  various  wasting  diseases.  We  doubt 
whether  its  connection  with  syphilis  is  anything  more  than  a  casual  one,  but 
it  is  certain  cranio-tabes  may  be  detected  in  weakly  infants  a  few  months  old 
who  exhibit  no  other  signs  of  rickets,  and  also  in  newly  born  infants.  Whether 
it  is  always  to  be  accepted  as  pathognomonic  of  commencing  rickets  is  an 
open  question  ;  but  when  present  in  infants  over  six  or  eight  months  of  age  it 
is  almost  always  in  our  experience  accompanied  by  signs  of  undoubted  rickets. 


Fig.  29. — Tracing  of  Chest  Wall  of  a  Rickety  Boy 
of  two  years  of  age. 


Fig.  30.  — Enlargement  of  Epiphyses  of 
Lower  End  of  Radius  and  Ulna. 
Child  of  eighteen  months. 


Characteristic  changes  take  place  in  the  chondral  ends  of  the  ribs  and  in 
the  shape  of  the  chest,  the  latter  being  most  marked  in  children  who  suffer 
from  bronchitis.  The  ribs  are  enlarged  or  beaded  where  they  join  their 
cartilages  :  these  may  be  fell  or  seen  at  a  glance  when  the  chest  is  exposed. 
The  shape  of  the  chest-walls  is  altered  in  consequence  of  the  softening  of  the 
costal  ends  of  the  ribs  ;  the  rigidity  of  the  chest  walls  is  impaired  at  this  spot, 
so  that  there  is  a  falling  in  of  the  ribs  on  each  side,  while  the  sternum  and 
cartilages  ai-e  thrust  forward  (see  fig.  29).  The  sides  of  the  chest,  especially 
the  region  included  between  the  fourth  and  eighth  ribs,  bend  or  curve  inwards 
so  that  a  more  or  less  broad  vertical  groove  is  formed  on  each  side  of  the 
chest.  The  angles  of  the  ribs  are  often  exaggerated  or  undergo  a  sharp 
bending  or  '  kink '  at  this  spot.  With  these  changes  is  mostly  associated 
a  widening  of  the  arch  which  the  ribs  make  inferiorly,  and  the  abdomen  is 


202 


General  Diseases 


distended  and  round.  If  the  child  be  watched,  especially  if  there  is  any 
bronchial  catarrh,  the  chest  walls  will  be  noticed  to  fall  in  at  the  groove  on 
each  side,  and  the  tip  of  the  sternum  is  drawn  in  during  inspiration.  All 
degrees  of  chest  deformity  may  be  present,  from  the  extreme  degree  noted 
above,  to  a  slight  prominence  or  keel-like  ridge  in  front,  formed  by  the  ster- 
num, which  makes  what  is  called  the  '  pigeon-breast.'  The  clavicle  often  joins 
in  the  deformit)^,  its  normal  double  curve  being  exaggerated.  The  extremities 
show  peculiar  changes,  more  especially  at  the  lower  epiphyses  of  the  radius 
and  ulna,  and  the  tibia  ;  the  shafts  are  very  apt  to  bend  and  in  the  worst  cases 
may  fracture.  The  lower  ends  of  the  radius  and  ulna  are  swollen,  the  swollen 
portion  involving  the  irregular  layer  of  cartilage, 
in  which  calcification  is  proceeding"  (see  fig.  31), 
which  separates  the  cartilage  of  the  epiphyses 
from  the  shaft;  in  the  worst  cases  this  enlargement 
is  very  striking  (see  figs.  30  and  31).  The  tibia  is 
usually  more  or  less  bent,  the  curve  varying  in 
position  and  degree  ;  the  lower  end  is,  however, 
most  commonly  bent  inwards  (being  an  exaggera- 
tion of  the  natural  curve),  so  that  the  convexity 
is  outward  (see  fig.  40  et  seq.),  a  deformity  which 
is  produced  by  the  child  whilst  sitting  on  the 
floor,  with  its  legs  ci'ossed  under  it,  shuffling 
with  its  legs  so  as  to  change  its  position.  The 
deformity  often  takes  place  before  the  child  learns 
to  walk.  The  deformity  known  as  '  knock- 
knees  '  is  produced  later,  after  the  child  has 
begun  to  walk  (see  fig.  39).  The  other  long 
bones,  the  femur  (see  fig.  34  et  seq.),  radius  and 
ulna,  and  the  humerus,  are  apt  to  bend  :  the 
bowed  humerus  is  sometimes  produced  by  the 
attendants  lifting  the  child  by  grasping  its  arms, 
Fig.  31.— Section  through  Radius  just  below  the  shoulder.      If  the  child  can  sit  up 

of  case  figured  in  fie.  30,  show-       ,  .         .  ,    ^       ,  ,  , 

ing  exaggerated  depth  and  irre-    the  spme  IS  apt  to  become  bowed,  an  exaggera- 
guiar  borders  of  the  proliferation    ^jg^j  gf  ^j^g   natural    curvc   taking  placc  in    the 

and  columnar  zones  of  cartilage.  .  .  i  1 

cervical  region,  while  the  dorsal  curve  is  ex- 
aggerated and  involves  the  lumbar,  so  that  the  spine  bows  out  backwards, 
a  result  largely  due  to  the  weakening  of  the  ligaments  (see  fig.  38). 

It  must  not  be  supposed  that  all  the  changes  in  the  shape  of  the  bones 
take  place  in  any  one  case,  and  the  degree  of  deformity  differs  according  to 
the  severity  of  the  case.  As  before  remarked,  the  shape  of  the  head  may  be 
quite  normal,  and  only  the  epiphysial  swelling  and  deformity  be  noted  in 
the  ribs  and  fore-arms.  Sometimes  muscular  weakness  is  the  symptom 
which  most  strikes  the  friends  :  the  child  is  dyspeptic,  has  a  rounded  belly 
and  pale  face,  the  teeth  are  late  in  appearing  ;  the  child,  who  is  perhaps 
eighteen  months  or  two  years  old,  cannot  stand  or  walk,  and  medical  advice 
is  sought  because  the  parents  think  the  legs  are  paralysed  ;  or  the  child  is 
brought  to  a  doctor,  as  it  is  supposed  he  has  spinal  disease,  on  account  of 
the  bowing  backwards  of  the  spine  ;  or  the  pigeon-breast  is  the  most  marked 
and  striking  symptom  which  alarms  the  friends. 


Rickets  203 

The  phenomena  noted  in  connection  with  the  nervous  system  in  rickets 
are  among  the  most  important.  The  whole  nervous  system  appears  to  be 
affected,  the  nerve  centres  are  in  an  unstable  condition  and  readily  discharge 
on  the  slightest  provocation.  General  convulsions  are  common,  more 
especially  during  the  early  stages  of  the  disease  ;  they  vary  much  in  their 
severity,  sometimes  being  slight  and  passing  away  quickly,  but,  on  the  other 
hand,  it  is  no  uncommon  thing  for  a  rickety  child  of  a  year,  eighteen 
months,  or  two  years  to  die  in  a  few  moments  in  a  fit.  Laryngismus  is 
common,  and  indeed  is  almost  confined  to  those  who  are  rickety.  Tetany 
is  also  common  in  rickety  children.  A  hypertrophic  condition  of  the  brain, 
with  a  large  head,  is  not  uncommon.  Rickety  children  are  exceedingly  liable 
to  bronchial  catarrh  and  broncho-pneumonia,  and  in  them  all  chest  troubles 
are  apt  to  be  serious.  They  are  liable  also  to  suffer  from  dyspeptic  troubles, 
especially  diarrhoea. 

In  the  severest  forms  of  rickets  the  child  is  apt  to  become  markedly 
anifmic,  and  when  this  is  so  there  is  usually  enlargement  of  the  spleen.  It 
has  been  doubted  if  splenic  enlargement  is  present  in  uncomplicated  rickets, 
or  in  those  cases  only  which  are  combined  with  syphilis.  We  certainly  have 
seen  cases  where  the  spleen  was  enlarged,  where  no  history  of  syphilis  could 
be  obtained.  With  enlargement  of  the  spleen  there  is  frequently  a  marked 
enlargement  of  the  liver. 

The  course  of  rickets  is  towards  recovery,  but  progress  is  frequently  very 
slow,  especially  in  those  cases  where  there  is  chronic  derangement  of  the 
digestive  organs.  The  child  is  certain  to  be  late  in  walking  ;  instead  of  '  feel- 
ing his  feet '  by  the  end  of  the  first  year,  he  is  utterly  helpless  when  his  legs 
are  put  to  the  ground,  and  at  the  end  of  the  second  or  even  the  third  year, 
rickety  children  may  be  seen  who  are  quite  unable  to  bear  their  own  weight 
on  their  legs.  All  this  time,  perhaps,  the  child  is  incapable  of  much  exertion 
and  is  easily  tired.  Many  dangers  attend  rickets  on  account  of  the  weakly 
state  of  the  child.  He  is  especially  liable  to  catch  cold ;  this  may  be 
followed  by  bronchitis  and  broncho-pneumonia.  The  latter  is  necessarily 
dangerous 'on  account  of  the  weakness  of  the  ribs  and  feebleness  of  the 
respiratory  muscles. 

Bronchitis  and  collapse  of  lung,  or  broncho-pneumonia,  are  exceedingly  apt 
to  be  fatal  when  they  complicate  rickets.  One  of  the  effects  of  rickets  is  to 
stunt  the  child's  growth,  as  well  as  to  leave  him  with  many  deformities,  which 
will  be  discussed  in  detail  later  on.  The  lowering  of  the  child's  health  pro- 
duced by  rickets  may  last  for  many  years,  but  in  the  vast  majority  of  cases 
the  symptoms  and  signs  of  rickets,  if  they  come  under  treatment,  disappear, 
and  the  child  may  grow  up  into  a  healthy  adult. 

Fa'tal  Rickets. — Congenital  Ricl^ets. — In  rare  cases  children  are  born  with 
deformed  bones,  enlarged  epiphyses,  and  beaded  ribs — a  condition  to  which 
the  name  of  rickets  can  hardly  be  denied.  Other  cases  have  been  observed 
in  which  the  bones  have  been  soft  and  deformed,  but  which  lacked  the 
characteristics — both  naked  eye  and  microscopic — of  rickets.  Hence  some 
confusion  has  ariseri,  and  the  terms  uifantile  osteo-malacia  and  achondro- 
plasia have  been  applied,  as  it  was  thought  they  resembled  these  rather  than 
rickets.  There  can  hardly  be  a  doubt,  however,  that  children  are  born 
rickety,  or  that  they  become  so  very  shortly  after  birth.     Such  cases  have 


204  General  Diseases 

been  observed  by  Bode,^  T.  Barlow,'-  and  the  late  Dr.  Marshall  (of  Preston). 
In  Bode's  case  the  infant  was  stillborn,  the  mother  was  healthy.  Tl^e  infant's 
head  was  hydrocephalic,  the  limbs  were  short  and  bent,  the  chest  deformed, 
and  the  ribs  beaded  ;  the  pelvis  was  narrow.  The  microscopical  examina- 
tion showed  changes  resembling  those  found  in  rickets.  In  Dr.  Barlow's 
case  there  was  a  history  of  the  infant  being  born  with  deformed  limbs,  which 
were  also  tender,  and  when  seen  at  six  weeks  old  the  long  bones  and  ribs 
were  typically  rickety,  and  there  was  a  green-stick  fi'acture  of  the  humerus. 
Dr.  Marshall's  case  was  somewhat  similar.     (See  Cretinism.) 

Morbid  Anatomy. — The  most  striking  appearances  in  connection  with 

rickets  consist  in  the  changes  of  the  bones.     In  the  first  place,  chemical 

analysis  shows  there  is  a  deficiency  of  lime  salts  in  their  constitution,  and 

an  excess  of  organic  matters.     Normal  bone  contains,  roughly,  65  per  cent. 

of  inorganic  constituents  and  35  per  cent,  of  animal  matters  ;  in  rickets,  all 

degrees  of  decrease  of  inorganic  matters  may  take  place,  but  in  a  severe  and 

well-marked  case  the  proportions  are  reversed,  so  that  there  is  only  about 

35  per   cent,  of  mineral  basis  and  65  per  cent,    of  gelatinous  or  organic 

matters  (A.  Baginsky).    That  there  is  a  deficiency  in  calcium  salts  is  evident 

from  the  spongy  nature  of  the  bone,  its  softness,  and  the  readiness  with  which 

it  'bends  ;'  while  the  spaces  between  the  bony  trabecule  are  seen  to  be  filled 

with  juicy  material.    If  a  rib  taken  from  a  well-marked  case  of  rickets  during 

the  acute  stage  be  examined,  it  will  be  found  not  only  to  be  wanting  in 

rigidity,  but  it  can  be  bent  about  like  a  thin  lath,  and,  if  doubled  up,  fractures  or 

'  gives '  with  the  greatest  ease  ;  the  fracture  may  be  only  partial,  or  perhaps  the 

ends  of  the  bones  are  only  held  together  by  the  fibrous  and  muscular  tissues 

attached  to  them.    In  the  same  way  the  forearm  of  the  cadaver  may  perhaps 

be  bent  by  taking  it  in  the  two  hands  and  applying  moderate  force,  or  it  may 

'  kink,'  and  on  dissection  both  radius  and  ulna  will  be  found  to  be  fractured 

Other  long  bones  may  behave  in  a  similar  way  if  sufficient  force  is  apphed. 

The  ribs,  where  they  join  the  cartilages,  will  be  noted  to  be  much  swollen  ; 

fractures,  recent  and  old,  may  be  present  at  the  angles  of  the  ribs  and  the 

lower  ends  of  the  radius  and  ulna  where  they  join  the  epiphyses.    A  section  can 

readily  be  made  with  a  strong  knife  through  the  enlarged  end  of  the  rib,  and  if 

made  in  a  direction  from  before  backwards  it  will  be  seen  in  most  cases  that 

the  pleural  side  is  more  prominent  than  the  external  side  of  the  swelling,  and, 

moreover,  the  enlargement  is  produced  by  the  expansion  of  that  portion  of 

cartilage — the  proliferation  and  columnar  zones — in  which  certain  changes 

are  going  on  preparatory  to  the  deposition  of  Hme  salts  in  the  matrix  of  the 

cartilage.      If  a  comparison  be  made  with  the  end  of  a  healthy  child's  rib, 

it  will  be  seen  in  the  latter  that  between  the  cartilage  of  the  rib,  which  is 

yellowish  and  opaque,  and  the  cancellous  tissue  of  the  rib,  there  is  a  line  of 

translucent  and  bluish  cartilage,  about  \  inch  in  breadth  at  birth,  and  about 

2^^  inch  at  a  year  or  eighteen  months  old  (Kassowitz)  ;  this  line  is  perfectly 

regular  and  straight  ;  the  breadth  of  it  depends  upon  the  rapidity  with  which 

growth  is  going  on,  which  is  greater  during  the  last  months  of  foetal  hfe 

and  those  immediately  succeeding  birth  than  it  is  later.     In  rickets  the 

activity  of  these  preparatory  changes  in  cartilage  is  enormously  increased,  so 

1   X'irchovv's  Archiv,  93,  Heft  iii.  -  Clin.  Soc.  Trans,  vol.  x.\i. 


Rickets 


205 


that  the  multipHcation  of  cartilage  cells  takes  place  with  great  rapidity,  and 
with  this  there  is  a  softening  of  the  cartilage  and  matrix,  and  a  conseciuent 
increase  in  size  of  the  proliferation  and  columnar  zones,  so  that  the  trans- 
lucent line  seen  in  normally  growing  bone  is  increased  in  breadth  to 
perhaps  \  inch  or  more,  and  there  is  a  bulging  or  swelling  in  this  position 
which  is  visible  through  the  skin  of  the  chest  walls  and  corresponds  to  the 
junction  of  the  ends  of  the  ribs  with  their  cartilages  (see  fig.  32).  Not  only 
does  this  normal  line  become  a  broad  band  of  jellylike  material  interposed 
between  the  cartilage  and  bone, 

but  the  boundary  between  it  and  V  '■'■'^Msia    \ 

the  cancellous  tissue  is  very 
irregular  and  ill-defined,  inas- 
much as  an  irregular  calcifica- 
tion   of    the    matrix    is     going 

on,   and   trabeculte    of  calcified 

material    with    wide    medullary 

spaces  are  being  formed  instead 

of    true    cancellous    tissue.       A 

spongy     structure    is     built    up 

which    is    wanting    in    strength 

and   rigidity.      Similar    changes 

are  going  on  beneath  the  perios- 
teum :  there  is  a  calcification  of 

the  inner  layer,  and  spongy  bone 

is    built  up  instead  of  the  firm, 

hard,  compact  tissue  which  forms 

the  outer  shell  of  healthy  bone 

(see  fig.  23)-     It  is  clear  that,  if 

the    compact   hard  bone    which 

forms  the  shaft  of  the  bone  is 

replaced  by  trabeculse  or  arches 

of  brittle,   badly   formed   bone, 

the  bone  will  readily  bend  and 

snap,  and  be  simply  held  to- 
gether by  the  fibrous  periosteum  p;g  ^2. 

and  perhaps  some  of  the  fibroid 

material    which    forms    in     the 

substance    of    the    bone    itself. 

The  bones  may  remain  soft  and 

brittle   for    many    months,    but 

finally  they  harden,  perhaps  in  a 

faulty  position,  and  a  sort  of  sclerosis  or  eburnation  of  bone  takes  place,  so 

that  the  compact  tissue  of  the  bone  is  abnormally  hard.     Should  a  fracture 

take  place  there  is  a  large  amount  of  callus  formed  at  the  seat  of  fracture. 

In  acute  cases,  or  in  those  in  which  the  haemorrhagic  diathesis  is  present, 

bleedings  large  or  small-may  be  found  beneath  the  periosteum  and  along 

the  line  of  junction  between  the  epiphysis  and  the  shaft. 

The  bones  of  the  skull  are  abnormally  soft  and  can  be  readily  cut  with  a 

knife,  and  are  much  more  readily  bent  or  doubled  up  than  are  healthy  bones. 


-Longitudinal  section  through  the  junction  of  a 
Rib  and  its  Cartilage,  from  a  Rickety  Child  of  two 
years,  x  lo.  (Kassowitz.)  /'/,  pleural  side  ;  A,  normal 
cartilage  ;  B,  proliferation  zone,  deeper  than  normal  ; 
C,  columnar  zone,  depth  and  breadth  much  increased  ; 
/ntj>,  deposition  of  lime  salts  in  the  cartilage—'  meta- 
plastic '  ossification  ;  S^.  spongy  tissue,  with  wide 
spaces  filled  with  soft  grumous  material,  containing 
many  cells  ;  v,  v,  v,  blood-vessels. 


2o6 


General  Diseases 


Their  edges  are  thickened  and  spongy  on  section,  much  juicy-looking  fluid 
exuding  ;  the  ossifying  centres  are  usually  thickened,  so  that  the  frontal  and 
parietal  eminences  are  exaggerated.  In  some  cases  prominences  or  bosses 
may  be  present  on  the  parietal  or  frontal  bones,  near  the  sutures  ;  but  it  has 
been  denied  that  these  are  really  rickety  changes,  though  they  certainly  do 
occur  in  rickety  subjects.  Instead  of,  or  in  association  with,  the  hypertrophic 
changes  just  referred  to,  certain  atrophic  changes  take  place,  the  bone 
becoming  thin,  almost  transparent,  in  places  ;  this  thinning  of  the  bone  is 
chiefly  present  in  the  parietal  and  occipital  bones.  If  the  dura  mater  be 
stripped  off  and  the  bone  held  up  to  the  light,  it  will  be  seen  to  be  thin  in 

places,    perhaps    almost    as    thin    as 


parchment  ;  at  these  spots  it  readily 
yields  to  the  pressure  of  the  finger, 
bending  in  under  the  slightest  force. 
Rickety  skulls  are  usually  large  ones, 
not  only  that  they  look  large  in 
consequence  of  the  thickness  of  the 
prominences  on  the  parietal  and 
frontal  bones,  but  their  capacity  is 
increased,  the  brain  being  larger 
than  usual  ;  it  is  possibly  the  pres- 
sure of  the  brain  within  that  causes 
the  atrophic  changes  in  the  bone. 

The  changes  found  in  the  internal 
organs  are  not  usually  very  marked 
unless  death  has  taken  place,  as  it 
not  infrequently  does,  from  broncho- 
pneumonia :  then  varying  degrees  of 
bronchitis,  pneumonia,  and  collapse 
of  lung  are  present.  The  brain  is 
frequently  found  of  large  size,  the 
convolutions  well  marked,  the  sub- 
stance fairly  firm  ;  such  brains  are 
said  to  contain  an  excess  of  the 
neuroglia  elements.  The  liver  and 
spleen  are  usually  enlarged  and  firm, 
and  the  former  on  section  has  a 
'  gummy '  or  more  or  less  translucent 
appearance.  Concerning  the  blood  but  few  observations  have  been  made. 
Dr.  Goodhart  has  observed  in  some  of  his  cases  a  deficiency  of  corpuscles, 
in  some  deficiency  of  colouring  matters,  in  some  the  blood  crowded  with  a 
granular  detritus,  and  in  others  the  corpuscles  were  of  four  or  five  different 
sizes. 

The  most  recent  examinations  of  the  blood  in  rickets  have  been  made  by 
Felsenthal,  who  examined  the  blood  in  twelve  cases  of  rickets,  varying  in  age 
from  six  months  to  two  years.  He  found  the  number  of  red  blood  corpuscles 
nearly  normal,  but  the  haemoglobin  diminished  (40  to  50  per  cent. — Fleischel), 
the  number  of  white  corpuscles  was  increased  two  to  five  times.  In  severe 
cases  some  of  the  red  corpuscles  were  nucleated. 


^ig-  -as- —Transverse  section  through  the  Shaft 
of  the  Ulna  from  a  Rickety  Child  of  thirteen 
rnonths.  x  lo.  (Kassowitz.)  Showing  spongy 
tissue  beneath  the  periosteum  instead  of  the 
compact  tissue  of  normal  bone. 


Rickets  207 

Treaii)ie7it.—  \i  x\c\i&\.s  is  due  to  the  mal-assimilation  of  the  products  of 
digestion  or  to  faulty  digestive  processes,  we  can  hardly  hope  to  discover 
any  specific  for  its  cure,  but  must  direct  all  our  efforts  to  secure  that  suit- 
able nourishment  in  appropriate  quantities  is  taken,  and  that  the  digestive 
apparatus  shall  be  in  good  working  order.  Directly  the  first  symptoms 
make  their  appearance,  whether  they  are  tenderness  of  the  bones,  sweating 
about  the  head,  or  enlarged  epiphyses,  spongy  gums,  hematuria,  we  should 
carefully  inquire  into  the  diet,  as  it  is  probable  that  the  child  is  either  not 
digesting  its  food  properly,  or  it  is  not  being  properly  fed.  The  condition  of 
the  digestive  organs  and  the  state  of  the  blood  act  and  react  on  each  other, 
the  intestinal  juices  are  weak  because  the  blood  from  which  they  derive  the 
materials  to  form  their  secretions  is  weak  and  poor  in  quality,  and  the  blood 
remains  of  poor  quality  because  the  digestive  juices  are  feeble  and  unable  to 
convert  albumen  into  peptones,  and  supply  the  first  step  towards  converting 
the  food  taken  into  blood.  The  child  suffering  from  rickets  in  the  acute 
stages  requires  albuminous  and  fatty  foods  in  the  most  easily  digested  forms, 
such  as  cream,  whey,  raw  meat  juice,  while  all  forms  of  peptonised  or  tinned 
foods  should  be  interdicted.  Probably  it  will  be  found  that  a  child  so 
affected  is  suffering  from  dyspepsia,  the  abdomen  is  large  and  distended 
with  gases  given  off  during  intestinal  digestion,  while  large  masses  of  un- 
digested curd  are  being  passed.  The  treatment  must  be  commenced  by 
cutting  down  the  supply  of  curd  of  milk,  by  diluting  it  largely  with  whey 
or  barley  water.  In  the  worst  cases  milk  may  have  to  be  withdrawn  entirely 
for  a  while,  and  raw  or  semi-cooked  meat  juice,  with  barley  water,  substituted. 
In  older  children  pounded  raw  meat  may  be  given.  Dextrin  and  maltose 
in  any  form  are  preferable  to  sugar  in  excess  or  starches.  Cream  in  small 
quantity  will  often  agree,  though  fat  in  the  form  of  cod  liver  oil  is  often  more 
readily  digested  than  any  other  form.  A  well-made  emulsion  may  be  given 
at  any  time,  beginning,  if  there  is  much  digestive  disturbance,  with  a  few 
drops  only,  care  being  taken  not  to  give  an  excessive  quantity.  Orange, 
lemon,  grape  or  apple  juice  should  be  given  in  all  cases  where  there  is 
tenderness  of  the  bones.     Potato  pulp  is  useful  in  the  same  condition. 

The  importance  of  fresh  air,  especially  sea  air,  in  the  treatment  of  rickets, 
cannot  be  over-estimated,  and  when  the  disease  first  declares  itself  a  change 
to  the  seaside  or  into  the  country  if  the  weather  is  warm  enough  is  likely  to 
be  attended  with  the  greatest  benefit.  In  urging  the  friends  to  send  the 
child  out  into  the  open  air  the  tendency  which  rickety  children  have  to 
bronchitis  must  not  be  forgotten,  and  the  importance  of  warm  woollen 
garments  must  be  insisted  on  ;  especially  is  this  important  where  there  is 
much  sweating.  If  the  weather  is  cool,  the  child's  feet  should  be  carefully 
wrapped  up  while  he  is  out  in  his  carriage  ;  a  bottle  of  hot  water  at  his 
feet  will  often  prevent  a  chill. 

The  most  careful  handling  must  be  practised  in  severe  cases,  as  the 
bones  easily  fracture  or  a  haemorrhage  may  take  place.  The  prone  position 
on  soft  cushions  in  a  cot  or  carriage  is  better  than  much  nursing  in  the  arms, 
as  the  limbs  are  easily  bent  and  the  spine  bows  out  if  the  child  is  allowed 
to  sit  up  much. 

Of  medicines,  the  most  important  are  those  which  assist  digestion  or 
correct  the  faulty  condition  of  the  mucous  membrane  of  the   stomach  and 


2o8  General  Diseases 

bowels,  and  those  which  aid  nutrition  and  improve  the  character  of  the  blood. 
Vomiting,  constipation,  dyspepsia,  and  diarrhoea  must  be  treated  by  appro- 
priate medicines  :  small  doses  of  mercury  and  chalk,  rhubarb  and  soda 
pepsine  or  bismuth  ;  care  should  always  be  taken  to  overcome  the  constipa- 
tion so  often  present.  Of  tonics,  cod-liver  oil  emulsion,  or  cod-liver  oil  in 
combination  with  malt  extract,  is  by  far  the  most  important,  though  in  practice 
it  is  common  to  find  it  is  being  given  in  excessive  quantities  and  at  a  time 
when  the  digestion  is  enfeebled.  In  such  cases  it  may  be  given  by  inunction. 
Phosphate  of  soda  with  tartrate  of  iron  and  glycerine  is  a  useful  tonic,  assist- 
ing the  action  of  the  bowels  and  combating  the  anaemia  so  often  present. 
Iodide  of  iron  is  also  useful. 

Small  doses  of  phosphorus  have  been  given  by  Kassowitz,  Wegnei",  and 
A.  Jacobi,  who  claim  for  it  an  almost  specific  action.  Other  physicians 
have  been  disappointed  with  the  results  obtained  by  its  administration.  It 
may  be  given  in  doses  of  5^^  to  j^i^  gr.  in  cod  liver  oil,  two  or  three  times  a 
day. 

Rickety  Deformities. — Distortions  of  the  lower  limbs  as  a  result  of 
rickets  form  a  large  and  important  group  of  the  deformities  of  childhood. 
Most  commonly  all  the  long  bones  of  the  limb  are  affected,  and  there  may  or 
may  not  be  distortion  of  the  articular  surfaces  at  the  knee.  In  many  instances 
the  deformity  is  limited,  or  at  least  most  marked  either  in  the  shaft  of  the 
femur,  the  lower  third  of  the  tibia,  or  the  lower  end  of  the  femur. 

Curvature  of  the  shaft  of  the  femur  takes  place  either  with  its  convexity 
forwards  or  in  severe  cases  forwards  and  outwards.  There  is  then  a  wide 
space  between  the  thighs,  and  the  quadriceps  stands  out  very  prominently 
over  the  convexity  of  the  bone  ;  the  patient  is  short  and  stunted-looking, 
the  gait  waddling,  and  there  is  knock-knee  or  bow-leg  to  a  greater  or  less 
degree. 

The  whole  of  the  shaft  takes  part  in  the  curve,  as  is  seen  in  fig.  34.  In 
this  child  the  deformity  was  extreme,  and  was  accompanied  by  so  much 
rotation  of  the  lower  end  of  the  femur  upon  a  vertical  axis  that  the  leg  and 
foot  faced  directly  outwards  instead  of  forwards.  A  condition  of  coxa  vara 
was  no  doubt  also  present  in  this  case.  Osteotomy  was  performed  at  the 
most  convex  part,  and  the  limb  turned  round  as  well  as  straightened,  so  that 
ultimately  the  feet  were  natural  in  position  (fig.  36).  Sometimes  the  curve  is 
limited  to  the  lower  end  of  the  diaphysis. 

Rickety  deformities  of  the  upper  limb  are  seldom  of  such  extent  as  to 
interfere  with  the  perfect  use  of  the  arms  or  to  require  operative  treatment. 
Obviously  this  is  because  no  such  strain  is  put  upon  the  arms  as  upon  the  legs 
in  childhood.  It  is  rare  for  even  the  application  of  splints  to  be  necessary, 
and  we  have  hardly  ever  had  occasion  to  straighten  forcibly,  never  to  osteo- 
tomise,  a  rickety  deformity  of  the  arms.  The  distortions  are  most  commonly 
produced  by  the  child  crawling  upon  the  hands,  and  consist  chiefly  in  bend- 
ings  of  the  shafts  of  the  bones.  We  have,  however,  seen  a  condition  analogous 
to  genu  valgum^  but  reversed — i.e.  instead  of  the  normal  outward  obliquity 
of  the  fore-arm  in  extension,  it  was  directed  inwards  so  that  the  convexity 
of  the  bend  was  outwards  at  the  elbow  {cubitus  varus)  ;  this  disappeared 
during  flexion  as  in  ge7iu  valgum,  and  was  probably  due  to  a  similar  bony 
condition,  though  we  could  not  satisfy  ourselves  of  the  exact  seat  of  deformity. 


Fig.  35.— Shows  the  attitude  habitually  assumed  by 
this  child,  which  resulted  in  the  deformity  shown  in 
fig-  34- 


Fig.  34. — Rickety  Deformity  of  the  Femora, 
caused  by  the  attitude  shown  in  the  next 
figure.  There  was  no  doubt  a  condition  of 
'  coxa  vara  '  in  this  case. 


Fig.  36. — The  same  child  shown  in  the 
last  two  figures.  The  limbs  have  been 
straightened  by  osteotomy. 


Fig.  37. — A  child  aged  7  years,  showing  extreme  stunt- 
ing frorn  premature  Synostosis,  as  well  as  various 
deformities,  all  the  result  of  Rickets.  The  child 
could  not  stand  alone. 


2IO 


General  Diseases 


A  similar  condition  may  occur  as  a  result  of  separation  of  the  lower  epiphysis 
of  the  humerus  and  irregular  union.  In  the  humerus  the  deformity  consists 
usually  in  curvature  with  the  convexity  outwards. 

The  rickety  deformities  chiefly  amenable  to  surgical  treatment  are  those 
of  the  spine  and  limbs  ;  distortions  of  the  chest  and  pelvis  can  only  be 
improved  by  general  management  of  the  health,  and  prevented  from  getting 
worse,  though  gymnastics  directed  especially  to  exercise  the  inspiratory 
muscles  other  than  the  diaphragm,  and  to  increase  the  inspiratory  capacity, 
are  of  great  value  in  the  treatment  of  rickety  chests.  For  the  pelvis,  even 
if  the  distortion  is  noticed  before  adult  hfe,  nothing  can  be  done  except  to 
prevent  the  deformity  from  being  increased.^ 

The  rickety  spine  is  met  with  in  two  forms  :  in  one  there  is  a  general 
curve  convex  backwards,  kyphosis  (fig.  38),  affecting  the  whole  dorso-lumbar 

region  ;     in    the    other    there    is    lordosis 

(fig.  37). 

The  first  form  is  that  met  with  in  infants 
and  young  children  before  they  begin  to 
walk  ;  the  other  variety  is  usually  secon- 
dary to  deformities  of  the  lower  limbs, 
and  is  therefore  most  frequently  met  with 
after  the  age  of  two  years.  Lateral  cur- 
vature is  considered  later. 

The  kyphotic  rickety  spine  is  readily 
distinguished  from  other  spinal  curva- 
tures by  the  age  of  the  child,  the  evidence 
of  rickets  elsewhere,  the  extent  of  the 
curve,  which  is  large  and  rounded,  never 
acute  or  angular,  and  the  flexibility  of  the 
spine,  so  that  by  laying  the  child  flat  or 
holding  it  horizontally  by  its  arms  and 
thighs,  face  downwards,  the  curve  speedily 
disappears.  Care  must,  of  course,  be 
taken  in  applying  this  test.  Finally, 
there  is  no  pain,  except  in  some  cases 
the  general  rickety  tenderness,  and  no 
evidence  of  caries  in  the  shape  of  abscess, 
paralysis,  &c.  The  attitude  of  a  child 
suffering  from  rickety  spine  is  well  seen 
in  fig.  38  as  compared  with  that  in  caries  (figs.  166,  167). 

All  that  is  required  in  this  condition  is  the  general  treatment  of  the  rickets 
and  recumbency,  not  implying  by  this  that  the  child  is  to  be  kept  in  bed  in 
a  stuffy  room,  but  that  it  is  not  to  be  kept  sitting  up  on  its  nurse's  lap, 
except  for  very  short  periods  at  a  time.  These  means  should  be  continued 
until  the  health  is  improved,  and  the  spinal  muscles  strengthened  by  friction 

1  Chance,  quoted  by  Noble  Smith,  found  pelvic  deformity  in  only  16  cases  out  of  600 
rickety  patients,  while  Reeves  found  it  in  210  cases  out  of  1,000.  Lane  believes  the 
deformities  of  the  lower  limbs  are  all  secondary  to  alteration  in  the  shape  of  the  sacrum. 
His  paper  in  the  Lancet,  August  9,  1890,  should  be  read  by  those  interested  in  the  mode 
of  production  of  deformities. 


. — Rickety  Curvature  of  the  .Spine. 
The  Antero-posterior  form. 


Rickety  Deformities 


21  I 


and  salt-water  bathing.     Unless  neglected,  the  spine  always  recovers,  and 
regains  or  rather  develops  its  natural  curves. 

The  lordosis  of  rickets  may  be  mistaken  for  a  secondary  deformity  due  to 
hip  disease,  congenital  dislocation  of  the  hips,  &c.,  but  the  absence  of  these 
conditions  is  readily  made  out,  and  other  rickety  deformities  will  be  found 
present.  Its  appearance  is  seen  in  fig.  yj,  which  may  be  compared  with 
that  of  a  case  of  congenital  dislocation  (fig.  192). 

It  should  be  remembered  that  lordosis  always  results  from  some  cause 
tending  to  throw  the  upper  part  of  the  spine  forward  in  standing,  such  as 
caries  of  the  upper  part  of  the  column,  stiffness  of  the  hip  joints,  distortion 
of  the  legs,  or  undue  weight  in  the  upper  part  of  the  body  or  head  ;  in  very 
rare  instances  lordosis  may  result  from  caries  of  the  spine  directly,  chiefly 
when  the  arches  are  the  seat  of  disease  :  it  is  then  due  either  to  actual  de- 
struction of  the  arches  or  to  muscular  spasm.  Lordosis  combined  with  a 
lateral  curve  may  result  from  uni- 
lateral deformity  of  the  lower  limb  in 
infantile  paralysis,  loss  or  shortening 
of  one  leg,  &c.  ;  all  these  possibilities 
should  therefore  be  kept  in  mind  before 
it  is  concluded  that  the  condition  is 
simply  rickety. 

As  the  lordosis  is  usually  secondary, 
as  already  stated,  to  deformities  of  the 
legs,  its  treatment  must  be  secondary 
to  that  of  the  limbs,  and  no  special 
applications  or  apparatus  are  required. 

Where  it  is  compensatory  to  an- 
gular curvature,  it  is,  of  course,  neces- 
sary, and  does  not  admit  of  treatment. 

Coxa  vara. — A  deformity  of  the 
neck  of  the  femur  consisting  in  a 
curvature  downwards  or  depression  of 
the  line  of  the  neck  in  relation  to  the 
line  of  the  shaft  of  the  bone,  together 
with  a  forward  curve  of  the  neck,  is  not 
seldom  seen  in  cases  of  very  severe  rickets,  and  produces  a  condition  which 
has  been  described  as  '  coxa  vara  ' — it  is  a  '  bowing  of  the  hip.'  Since  the 
neck  of  the  femur  is  depressed  the  trochanter  rises  and  becomes  prominent, 
and  the  limb  is  shortened.  Nelaton's  line  or  Bryant's  triangle  will  show 
displacement.  The  limb  is  also  everted,  and  an  awkward,  waddling  gait  and 
some  stiffness  result.  The  condition  is  readily  distinguished  from  '  congenital 
dislocation '  of  the  hip  by  the  absence  of  undue  mobility.  Though  most  com- 
monly due  to  rickety  deformity,  coxa  vara  may  result  from  injury,  or  from 
chronic  or  acute  disease  of  the  upper  end  of  the  femur.  A  certain  amount  of 
pain,  especially  after  long^  walking,  and  a  limitation  of  movements  of  rotation 
inward  and  of  abduction  are  found.  We  are  inclined  to  think  that  a  certain 
degree  of  this  curvature  of  the  neck  of  the  femur  is  exceedingly  common  in 
cases  of  rickety  deformity  (see  figs.  34  and  37).  The  treatment  is  that  of  the 
disease  with  avoidance  of  anything  that  throws  stress  or  weight  upon  the 

p  2 


^  Ajb 


Fig.  39. — An  ordinary  case  of  Knock-knee. 


212  Genei^al  Diseases 

femoral  neck.  Only  in  extreme  and  firmly  ossified  cases  is  any  operative 
treatment  required.  In  such  condition  osteotomy  of  the  upper  end  of  the 
femur  and  rotation  and  abduction  of  the  limb  would  be  justifiable.  The 
deformity  may  appear  at  any  time  after  the  child  begins  to  walk. 

Knock-knees. — Deformity  of  the  lower  end  of  the  femur,  resulting  in 
knock-knee  or  genu  valgum^  occurs  in  several  different  ways  besides  the 
one  already  described.  The  inner  part  of  the  shaft  at  the  epiphysial  line 
sometimes  grows  more  rapidly  than  the  outer  (Mickulicz)  ;  hence  the  inner 
half  of  the  shaft  is  longer  than  the  outer,  the  inner  condyle  descends  lower, 
the  line  of  the  knee-joint  becomes  oblique,  and  the  tibia  is  set  at  an  obtuse 
angle  with  the  femur.  This  condition  may  be  due  to  premature  synostosis 
at  the  outer  half  of  the  growing  line  (Oilier  and  Tripier),  a  condition  found 
so  often  in  rickets,  and  explaining  largely  the  stunted  form  of  extreme  cases. 
( Vide  figs,  yj  and  42.)  Sometimes  the  same  results  follow  from  absolute 
overgrowth  of  the  inner  half  of  the  epiphysis  and  the  internal  condyle  as 
compared  with  the  outer.  In  other  instances,  dependent  upon  the  irregular 
ossification  characteristic  of  rickets,  the  outer  condyle  does  not  develop,  and, 
though  the  inner  half  of  the  epiphysis  is  not  absolutely  larger  than  in  health, 
it  is  so  relatively  to  the  aborted  external  part.  Again,  the  soft,  ill-developed 
rickety  bone,  though  symmetrical  at  one  time,  actually  wastes  or  is  absorbed 
as  the  result  of  pressure,  and  a  corresponding  deformity  results.  No  doubt  in 
some  of  these  children  a  yielding'  of  soft,  ill-formed  ligaments  is  the  primary 
condition,  and  the  bone  changes  only  occur  as  the  result  of  the  shght  obliquity 
produced  by  this  yielding.    The  deformity  is,  however,  sometimes  congenital. 

In  explaining  the  cause  of  the  particular  kind  of  deformity  it  must  be 
remembered,  first,  that  the  femur  is  normally  set  at  an  angle  with  the  tibia 
and  not  vertically  upon  it  ;  secondly,  that  these  children  often  assume  atti- 
tudes in  which  the  weight  of  the  body  and  limbs  so  presses  upon  certain 
parts  of  the  shafts  of  the  bones  that  they  yield,  and  curves  result.  Such 
deformities  are  produced  by  habitually  sitting  cross-legged,  as  is  seen  in 
fig.  35,  &c.  Other  reasons  are  that  in  certain  cases  congenital  inequality  in 
length  of  the  limbs  throws  the  weight  of  the  body  both  unequally  and 
obliquely  upon  one  leg  ;  ^  and  again,  where  the  deformity  has  arisen  before 
the  age  at  which  walking  begins,  the  pressure  of  the  nurse's  arms  and  the 
leverage  of  the  weight  of  the  limbs  themselves  acting  over  the  nurse's  arms  may 
produce  deviation.  Congenital  or  acquired  valgus,  slight  degrees  of  infantile 
paralysis,  or  any  cause  tending  to  throw  the  weight  out  of  the  normal  line, 
will  in  some  instances  prove  the  starting  point.  In  all  cases  it  is  clear  that, 
as  the  bones  are  soft  and  unduly  yielding,  a  pressure  that  would  have  no 
effect  upon  a  healthy  bone  will  cause  deviation  in  a  rickety  child,  and  that, 
when  once  the  curve  is  started,  it  will  always  tend  to  increase  more  rapidly. 

It  is  not  improbable  that  the  irregular  ossification  of  rickets  prevents  the 
normal  architecture  of  the  bone  from  being  built  up  and  so  weakens  it — i.e. 
the  special  arrangement  of  arches  and  struts  in  the  cancellous  tissue  is 
not  preserved. 

Sometimes  knock-knee  is  due  to  distortion  of  the  tibia  I'ather  than  the 
femur,  and  it  will  usually  be  found  that  the  upper  tibial  articular  surfaces 

1    Reeves  has  laid  stress  strongly  upon  this  fact. 


Rickety  Defoj'mities 


21 


are  misshapen  and  bevelled  off.     This   is,  however,  generally  a  secondary 
condition. 

•Ro^w-Xeis,  genu  varum  ox  genu  cxtrorsuni^M  a  deformity  which,  though 
dependent  upon  the  same  general  causes  as  knock-knee,  differs  from  it  in 
most  instances  in  its  mechanical  causes  ;  thus  it  is  rarely  dependent  upon 
a  local  inequality  of  growth  in  the  lower  end  of  the  femur,  but  is  usually  a 
general  as  opposed  to  a  local  curve  of  both  femur  and  tibia,  and  is  not 
limited  to  the  region  of  the  knee.  It  is  most  commonly  found  in  one  leg,  the 
other  being  the  subject  of  knock-knee,  and  in  such  cases  it  will  nearly 
always  be  found  that  the  knock-knee  has  appeared  first  and  the  bow-leg 
later  ;  in  fact,  the  bow-leg  is  the  result  of  the  knock-knee.  If  such  a  patient 
is  stripped,  it  will  be  found  that  the  axis  of  the  trunk  is  directed  from  one 
shoulder  obliquely  downwards  to  the  hip  of  the  knock-kneed  limb  :  then  the 
line  of  pressure,  following  the  axis  of  the  thigh  of  that  side  if  produced, 
would  pass  through  the  region  of  the  opposite  knee  :  hence  yielding  to  this 


Fig.  40. — Shows  how  sitting  '  cross-legged  ' 
produces  Curvature  of  the  Tibiae.  The 
right  foot  is  resting  on  the  ground. 


Fig.  41. — An  ordinary  case 
of  Bow-leg. 


pressure  produces  an  outward  bowing  of  the  whole  of  the  opposite  limb.  It 
is  true  that  the  curve  of  bow-leg  is  not  quite  even,  and  is  usually  sharpest 
at  the  weakest  part  of  the  leg — -the  lower  third  of  the  tibia  ;  much  more 
rarely  there  is  a  true  genu  varimi^  or  bowing  out,  mainly  at  the  knee  itself ; 
in  such  cases  the  head  of  the  fibula  is  usually  very  prominent. 

Double  genu  valgum  occurs  when  the  changes  in  both  legs  begin  at  the 
same  time  and  go  on  at  the  same  rate  ;  double  bow-leg  results  either  from 
local  changes  e.xactly  opposite  to  those  of  knock-knee,  or,  more  often,  is 
started  by  the  position  assumed  in  sitting  by  the  child,  and  increased  by  the 
weight  of  the  body  subsequently.  Thus  it  is  common  to  see  children  sitting 
on  the  floor  with  both  thighs  somewhat  abducted  and  rotated  outwards  ;  in 
this  position  the  limbs  rest  on  the  hips  and  ankles,  and  the  knees  are  quite 
unsupported.  The  weight  of  the  limbs  then  tends  to  bend  them  outwaixls, 
and  produces  bow-leg,  while,  if  the  feet  are  crossed  one  over  the  other,  the 
curve  will  be  most  marked  at  the  lower  third  of  the  tibia,  and  the  leg  which 


214 


General  Diseases 


rests  upon  the  other  will  have  more  of  an  anterior,  and  less  of  an  external, 
curve  than  its  fellow  (fig.  40). 

Deformities  of  the  tibia  are  more  complex  and  difficult  to  explain  than 
those  of  the  femur  ;  besides  the  general  outward  curve  already  described 
as  a  part  of  bow-leg,  there  are  found  curvatures  of  the  tibia  alone,  the 
femur  remaining  quite  or  nearly  straight.     The  most  common  curve  in  the 

tibia  is  a  sharp  bend  with  its  convexity  out- 
wards and  forwards  at  the  lower  third. 

Sometimes  there  is  a  projection  outwards 
and  backwards  of  the  upper  part  of  the  shaft, 
just  below  the  tuberosities,  giving  almost  the 
appearance  of  a  subluxation  backwards  at  the 
knee  joint.  There  is  sometimes  a  condition 
of  hyperextension  in  these  patients,  but  the 
appearance  is,  we  think,  often  due  to  the 
distortion  mentioned  (fig.  yj). 

In  some  cases  there  is  a  bend  forward  and 
inwards  at  the  middle  of  the  shaft,  or  rather, 
as  this  is  associated  with  genu  valgum^  it  is 
to  be  described  as  a  bending  outwards  and 
backwards  of  the  lower  half  of  the  leg  upon 
the  upper. 

It  is  common  in  severe  cases  of  gejiu 
valgum  to  find  a  well-marked  rotation  of  the 
tibia  upon  its  vertical  axis,  just  as  already 
described  in  the  femur,  so  that,  instead  of 
looking  inwards  and  forwards,  the  inner  or 
subcutaneous  surface  of  the  tibia  looks  almost 
directly  forwards  (or  sometimes  the  rotation 
is  inwards — Reeves)  ;  the  upper  third  of  the 
tibia  may  look  almost  directly  forwards,  the 
lower  third  inwards  and  backwards.  In  such 
cases  the  inner  border  of  the  tibia  is  very 
strongly  marked,  forming  a  prominent  ridge 
somewhat  spirally  twisted,  ending  below  at 
the  convexity  of  the  forward  curve,  and  above 
at  the  inner  side  of  the  internal  tuberosity 
{fig.  42).  In  many  cases,  especially  in  those 
of  long  standing,  whether  this  inner  border  is 
well  marked  or  not,  there  is  a  prominent 
spur-like  buttress  of  bone  developed  below  the  inner  tuberosity  at  the 
insertion  of  the  internal  lateral  ligament  ;  this  spur,  the  existence  of 
which  was,  we  believe,  first  pointed  out  by  Mr.  Clement  Lucas,  is  pro- 
bably the  result  of  ossification  of  the  ligament  as  a  result  of  strain  and 
irritation,  somewhat  as  in  the  case  of  '  rider's  bone '  and  other  instances 
of  bony  overgrowth  at  the  attachment  of  greatly  used  muscles.  The 
prominent  ridges,  as  stated  by  Mr.  Noble  Smith,  are  most  marked  when 
the  disease  is  arrested  and  the  stage  of  hyperostosis  has  come  on. 
Sometimes  there   is  a  flat  surface  of  bone  running  up  from    the   spur  to 


Fig.  42. — A  case  of  severe  Rickets, 
showing  most  of  the  commoner  de- 
formities, as  well  as  dwarfing  from 
Synostosis. 


Rickety  Defo^nnities  2 1 5 

the  inner  condyle  of  the  femur  (Macewen)  ;  in  severe  cases  this  is  very 
striking,  and'  the  spur  reaches  down  far  below  the  direct  insertion  of  the 
ligament.  Two  other  conditions  associated  with  these  deformities  require 
notice  :  one  is  that  the  patella  in  severe  cases  of  knock-knee  tends  to  ride 
outwards  upon  the  external  condyle,  and  even  to  be  dislocated  quite  to  its 
outer  surface  during  flexion  of  the  limb.  This  is  the  result  partly  of  deficient 
size  of  the  external  condyle,  and  partly  of  the  bony  curves,  so  that  the 
quadriceps,  acting  in  a  straight  line,  does  not  make  traction  in  the  axis  of  the 
bones.  The  patella  may  also  sink  so  deeply  into  the  intercondylar  notch 
in  flexion  that  its  position  may  be  marked  by  a  depression.  The  other  con- 
dition referred  to  is  the  direction  and  arch  of  the  foot.  In  knock-knee  the 
foot  would  naturally  point  outwards  in  consequence  of  the  alteration  in  the 
axis  of  the  limb,  while  in  bow-leg  the  toes  point  usually,  though  not  always, 
forwards  or  slightly  inwards.  Besides  this,  there  is  in  some  instances  flat- 
foot  more  or  less  severe.  It  has  been  asserted  that  flat-foot  is  really  the 
cause  oi genu  valgum^  but  that  this  is  not  so  in  by  any  means  most  cases  is 
readily  shown.  Very  often,  instead  of  flat-foot,  there  is  a  condition  oi  pes 
cavus,  together  with  a  peculiar  spasmodic  contraction  of  the  great  toe.  Both 
the  cavus  and  the  spasm  of  the  flexor  of  the  great  toe  are  evidently  due  to 
the  efforts  made  to  obtain  a  firm  grip  of  the  ground  in  order  that  the 
instability  caused  by  the  knock-knee  may  be  counteracted.  Sometimes  the 
great-toe  spasm  exists  when  flat-foot  is  present,  and  it  is  seen  in  bow-leg  and 
curve  of  the  tibia  alone  as  well  as  in  knock-knee.  The  foot  is  inverted  to 
prevent  strain  upon  the  internal  lateral  ligament  of  the  ankle,  the  flexors  of 
the  toes,  and  tibialis  posticus,  as  well  as  to  allow  the  foot  to  be  placed  flat 
upon  the  ground  ;  this  tends  to  bring  the  bearing  point  upon  the  outer  side 
of  the  foot  and  to  remove  the  ball  of  the  great  toe  from  the  ground  ;  then, 
to  compensate  for  this,  the  toe  is  flexed  so  that  the  last  phalanx  may  take  a 
share  in  the  support  of  the  body.  These  points  are  to  some  extent  shown 
in  the  preceding  figures.' 

To  summarise,  then,  the  following  deformities  may  exist  in  the  lower 
limbs  as  a*  result  of  rickets  : 

1.  'Coxa  vara'  or  a  curvature  of  the  neck  of  the  femur  downwards  and 
forw  ards,  or  less  often  backwards. 

2.  Curvature  of  the  shaft  of  the  femur,  with  its  convexity  forwards,  or 
forwards,  and  outwards  throughout  its  whole  length,  together  with  rotation  of 
the  lower  half  upon  the  upper  through  a  vertical  axis. 

3.  Diaphysial  overgrowth  on  one  side  of  the  growing  line,  absolute,  or 
relative  from  synostosis  of  the  other  halt. 

4.  Overgrowth  of  either  condyle,  with  absolute  or  relative  smallness  of  the 
other  condyle. 

5.  Curvature  of  the  lower  third  of  the  femur,  with  its  convexity  inwards 
(according  to  Macewen  the  commonest  cause  oi  genu  valgum). 

6.  Curvature  of  the  shaft  of  the  tibia  as  a  whole,  the  convexity  being 
directed  outwards. 

7.  Curvature  of  the  upper  part  of  the  tibia,  so    that    the    convexity    is 

'  Macewen  believes  that  flat-foot  occurs  in  children  before  walking,  but  that  on  walking 
the  cavus  and  toe  spasm  are  developed. 


2i6  General  Diseases 

directed  backwards  and  outwards  :  possibly  this  distortion  is  sometimes  at 
the  epiphysial  line. 

8.  Curvature  of  the  shaft  of  the  tibia  at  the  middle,  the  convexity  being 
directed  forwards,  or  forwards  and  inwards. 

9.  Curvature  of  the  shaft  of  the  tibia  at  its  lower  third,  the  convexity 
looking  forwards  and  outwards,  more  rarely  directly  forwards. 

10.  Rotation  of  the  tibia  spirally  upon  a  vertical  axis. 

11.  Overgrowth  of  the  ridges  on  the  tibia,  especially  the  internal  border 
and  the  region  below  the  inner  tuberosity  ;  similar  outgrowths  sometimes  occur 
about  the  internal  condyle  and  along  the  concavities  of  the  curves  of  the  femur, 
as  well  as  in  the  neighbourhood  of  any  of  the  epiphysial  lines. 

12.  Dislocation  of  the  patella  outwards. 

13.  YXdJi-ioo^^pes  cavus^  spasmodic  contraction  of  the  flexor  longus  pollicis. 

14.  The  muscles  and  ligaments  on  the  concavity  of  the  curves  in  either 
direction  may  be  contracted  and  shortened,  those  on  the  convexity  stretched 
and  weakened. 

15.  The  pelvis  and  lower  limbs  may  be  stunted  as  a  whole  from  lack  of 
development  or  premature  synostosis. 

Ibate  Rickets. — Though  perhaps  hardly  coming  into  the  category  of 
children's  diseases,  mention  must  be  made  of  the  so-called  '  late  rickets,'  or 
'  rickets  of  adolescence,'  in  which  deformities,  knock-knee,  flat-foot,  and 
more  rarely  bow-leg,  come  on  between  the  ages  of  twelve  and  twenty  years 
or  thei'eabouts,  the  deformity  being  a  bony  and  not  merely  a  muscular  or 
ligamentous  one  in  the  case  of  knock-knee. 

This  condition  has  been  attributed  to  a  disease  allied  to  osteomalacia  ; 
it  has  also  been  described  as  relapsed  rickets,  and  by  Mr.  Lucas  has  been 
said  to  be  associated  with  masturbation  and  albuminuria.  As  to  these  alleged 
causes  we  may  say  that  it  is  not  often,  we  think,  relapsed  rickets,  for  we  have 
seen  many  instances  where  there  was  no  evidence  that  rickets  had  ever 
existed  in  childhood.  It  is  not  osteomalacia,  for  the  patients  never  die  of  the 
disease,  the  process  becomes  arrested,  and  it  does  not  occur  under  the  con- 
ditions met  with,  nor  attack  the  parts  affected  in  osteomalacia.  It  is  certainly 
not  due  to,  nor  even  associated  with,  either  albuminuria  or  masturbation  in 
by  any  means  all  instances.  We  have  examined  such  patients  a  good  many 
times,  and  in  only  one  was  there  even  a  trace  of  albumen  in  the  urine,  and, 
as  is  well  known,  this  may  occur  quite  apart  from  the  condition  under  dis- 
cussion ;  in  none  of  our  cases  was  there  any  evidence  of  masturbation.  It 
is,  we  believe,  due  simply  to  weak  health,  bad  air,  long  standing,  poor  food — 
in  short,  to  bad  hygienic  conditions  at  a  time  when  growth  is  active  in  the 
limbs — in  fact,  mainly  to  those  causes  which  produce  rickets  in  earlier  life ; 
but  in  consequence  of  the  greater  strength  of  the  skeleton  and  its  more  com- 
plete ossification,  as  a  rule  it  only  produces  deformity  in  those  parts  on  which 
the  greatest  strain  is  thrown  ;  in  some  cases  there  is  well-marked  enlarge- 
ment of  the  epiphyses,  of  recent  appearance,  and  not  dating  back  to  the 
usual  time  of  rickets  :  this  we  have  seen,  and  other  cases  have  been  recorded 
where  both  the  external  and  microscopical  appearances  were  identical 
with  rickets.^     The  affection  is,  we  think,  best  described  as  late  rickets  ;  it 

1  Vide  Glutton,  St.  Thomas's  Hospital  Reports,  1884,  and  Mickulicz  referred  to  in 
Macewen's  book. 


Rickety  Deformities  217 

furnishes  a  large  number  of  the  patients  upon  whom  osteotomy  in  adult  life 
is  performed.' 

Summary. — A  child,  then,  suffering  from  knock-knee  the  result  of  rickets 
will  present  the  following  appearances  in  addition  to  evidences  of  rickets  in 
other  parts.     As  he  stands  the  femora  will  be  seen  to  project  markedly  for- 
wards and  outwards,  the  extensors  of  the  thigh  being  firm  and  prominent. 
There  is  often  some  flexion  of  the  thighs  upon  the  pelvis,  and  of  the  legs  upon 
the  thighs  ;  and  secondary  lordosis,  resulting  in  a  peculiar  doubled-up  and 
crouching  attitude.     The  legs  are  set  at  an  obtuse  angle  with  the  thighs,  the 
patelke  are  displaced  outwards,  and  the  internal  condyles  of  the  femora  look 
forwards  and  inwards,  instead  of  directly  inwards ;  the  whole  limb  is  in  fact 
rotated  outwards.     The  tibial  ridges  are  unduly  developed,  and  there  is  a 
spiral  twist  in  the  leg.     The  feet  are  directed  outwards,  though  the  toes  are 
somewhat   adducted,  and  spasmodically  grasp  the  floor,  the  flexors  being 
strongly  contracted,  especially  that  of  the  great  toe  :  the  arch  of  the  foot  is 
exaggerated,  or  may,  on  the  other  hand,  be  lost.     In  walking,  one  knee  passes 
in  front  of  the  other,  in  severe  cases  to  such  an  extent  that  the  appearance  is 
that  of  a  person  walking  cross-legged.     The  patient's  height  is  much  less 
than  it  should  be  from  the  actual  length  of  the  limbs,  and  he  is  easily  tired 
and  complains  of  aching  of  the  legs,  especially  on  the  inner  side  of  the 
knee  if  the  deformity  is  increasing.      In  other  instances,  however,  though 
much  deformed,  the  child  is  as  active  and  sturdy  as  his  fellows,  and  makes 
no  complaint  of  pain  or  tiredness  ;  when  this  is  so,  the  distortion  is  usually 
not  increasing.     On    examining   the   knees    more   closely  it  is   found    that 
on  flexion  of  the  joint  the    leg    can  be  brought    into    the    same    line    with 
the  thigh — a  result  due  to  the  slipping  back  of  the  tibia  from  the  more  promi- 
nent part  of  the  condyles  to  the  posterior  surface.     The   internal  condyle 
can  be  felt  to  be  larger  and  to  descend  lower  than  the  external,  so  that  if 
the  limb  is  placed  in  such  position  that  the  lower  borders  of  the  two  condyles 
are  on  the  same  level,  the  axis  of  the  femur  is  much  more  oblique  than  in 
a  healthy  limb  (Reeves).     The  patella  in  extension  keeps  its  natural  position  ; 
while  in  flexion  in  severe  cases,  as  already  noticed,  it  slips  outwards  and 
leaves  the  intercondylar  notch  plainly  perceptible,  the  appearance  being  much 
that  of  fig.  225.     On  attempting  to  straighten  the  limb  during  extension  this 
will  be  found  impossible,  though  a  little  lateral  movement  may  take  place, 
and  the  tendons  of  the  biceps  and  the  ilio-tibial  band  of  fascia  will  become 
very  tense.     The  head  of  the  fibula  is  sunken,  and  concealed  deep  within  the 
angle  between  the  tibia  and  femur.     The  seat  of  pain  and  the  tubercle  at  the 
insertion  of  the  internal  lateral  ligament  have  been  already  alluded  to. 

The  degree  of  deformity  present  varies  greatly,  but  never  reaches  nearly 
the  extent  in  children  that  it  does  in  adults  ;  in  an  adult  case  we  have  seen 
the  leg  almost  at  a  right  angle  with  the  thigh,  and  in  another  that  we 
operated  upon  there  was  19^^  inches  between  the  malleoli  when  the  inner 
condyles  were  in  contact.  In  double  geitu  valgum  ten  inches  deviation 
would  be  an  extreme  case  in  a  child,  and  five  inches  a  severe  one. 

In  measuring  the  deformity  it  is  best  to  lay  the  child  upon  a  flat,  hard 

1  Mr.  Reeves  in  Practical  Orthopcsdics  gives  an  elaborate  account  of  the  causation  of 
these  deformities,  which  we  are  not  altogether  able  to  follow. 


2i8  General  Diseases 

surface  ;  the  legs  must  then  be  fully  extended  and  rotated  inwards  until  the 
front  of  the  lower  end  of  the  femur  looks  directly  forwards  ;  the  two  internal 
condyles  are  then  to  be  put  just  touching  one  another.  A  vertical  line  is  then 
drawn  through  the  umbilicus  and  centre  of  the  pubes  downwards  to  the  level 
of  the  malleoli,  and  on  measuring  the  distance  from  the  inner  malleolus  on 
each  side  to  the  veitical  line  the  amount  of  deviation  will  be  ascertained.  In 
double  genu  valgum  the  line  will,  if  the  limbs  are  symmetrical,  pass  through 
the  point  of  contact  of  the  condyles,  while  in  bow-leg  it  will  lie  far  within  the 
arc  of  the  upper  part  of  the  limb,  but  may  pass  to  the  outer  side  of,  or  through 
the  ankle. 

Knock-knee  in  children  does  not  always  depend  upon  rickets,  and  it  is 
important  to  recognise  this  fact.  It  may  simply  be  the  result  of  lax  hga- 
ments  without  any  primary  or  even  secondary  alteration  in  shape  of  the 
bones  ;  thus  a  child  may  have  marked  genu  valgum  while  standing  up,  but 
on  lying  down  it  may  be  possible  to  bring  the  legs  perfectly  straight,  and  to 
again  produce  the  deformity  by  steadying  the  thigh  and  abducting  the  leg  ; 
a  distinct  gap  will  then  be  felt  between  the  femur  and  tibia  on  the  inner  side, 
and  lateral  rocking  may  be  easily  shown.  In  such  patients  the  deformity 
may  after  a  time  become  permanent  from  stretching  of  the  muscles  and 
ligaments  on  the  inner  side  and  contracture  of  those  on  the  outer  aspect. 

A  similar  deformity  in  one  of  our  patients  was  the  result  simply,  apparently, 
of  hysterical  contraction  of  the  muscles  on  the  outer  side,  Avith  weakness  of 
the  internal  set,  '  muscular  spasm  '  (Guerin). 

Treatment  of  Rickety  Defo7'mities. — The  degree  of  deformity,  the  age  of 
the  patient,  and  the  state  of  the  disease,  whether  stationary  or  getting  worse, 
and  the  amount  of  care  and  trouble  that  can  be  bestowed  upon  the  child,  are 
the  points  to  be  considered  in  the  treatment  of  these  cases.  Thus  it  is  useless 
to  attempt  to  treat  by  instruments  or  splints  a  very  severe  case  of  distortion, 
while,  on  the  other  hand,  it  is  rarely  necessary  to  perform  osteotomy  upon  a 
child  under  three  years  old  because  the  application  of  splints  with  or  without 
previous  forcible  straightening,  if  it  is  a  case  of  curve  of  the  tibia  alone,  will 
usually  suffice  for  a  cure.  Again,  if  the  deformity  has  been  stationary  for  some 
time  and  it  is  probable,  therefore,  that  the  post-rickety  sclerosis  of  bone  has 
taken  place,  it  is  useless  to  think  of  straightening  the  leg  without  operation, 
while  if  the  curvature  is  getting  worse,  it  is  probable  that  the  bones  are  still 
sufficiently  soft  to  yield  to  pressure.  Besides  these  considerations  comes  the 
very  important  one  of  the  amount  of  care  and  time  that  can  be  bestowed 
upon  the  child  ;  it  is  not  only  justifiable,  but  necessary,  to  perform  osteotomy 
upon  many  children  who  could  be  straightened  perfectly  well  without  operation 
if  they  could  be  seen  frequently  by  the  surgeon,  be  kept  off  their  legs,  and 
their  splints  properly  applied,  but  who  are  neglected,  allowed  to  get  about 
anyhow,  and  their  splints  are  applied  wrongly  or  not  at  all.  In  such  cases  it 
is  mere  waste  of  time  to  do  anything  short  of  operation  ;  hence  we  have 
frequently  osteotomised  or  forcibly  straightened  the  limbs  of  children  between 
two  and  four  years  old,  and  we  entirely  disagree  with  the  view  that  it  is  bar- 
barous to  operate  upon  young  children  who  could  be  straightened  without 
operation  if  it  were  possible  to  give  all  alike  the  same  care  and  time.  At  any 
rate,  it  is  practically  a  choice  between  their  remaining  crooked  and  osteotomy 
or  fracture.     The  general  constitutional  treatment  of  rickets  has  been  already 


Rickety  Deformities 


219 


considered  elsewhere.     The  local  treatment  consists  in  operative  and  non- 
operative  rneans. 

Treatment  withotit  Operatic?!. — In  a  young  child  with  the  deformity  in- 
creasing, but  not  very  severe,  who  can  be  well  looked  after,  the  treatment  of 
knock-knee  consists  in  forbidding  him  to  stand  at  all,  in  bathing  and  rubbing 
the  limbs  well  to  improve  their  circulation  and  muscular  power,  and  in  using 
firm,  steady  traction  in  the  direction  of  straightening  the  limb,  as  if  to  break 
the  leg  across  the  knee,  for  ten  minutes  at  a  time  night  and  morning,  such 
force  as  can  be  borne  without  pain  being  employed,  and  care  being  taken  that 
the  limb  is  fully  extended.  For  the  rest  of  the 
day  and  at  night  the  child  should  wear  a  light, 
slightly  hollowed,  straight  splint,  long  enough  to 
reach  from  the  top  of  the  trochanter  to  just  below 
the  sole  of  the  foot.  This  splint  should  be  fixed 
to  the  upper  part  of  the  thigh  and  the  lower  part 
of  the  leg  by  inelastic  webbing  straps,  while  over 
the  prominence  of  the  knee  an  elastic  strap  should 
be  applied  to  draw  the  knee  outwai-ds  against 
the  splint  ;  we  prefer  this  plan  to  bandaging  only. 
As  soon  as  the  child's  health  is  improved,  or  if  the 
case  is  very  slight,  a  shorter  splint  may  be  em- 
ployed and  he  may  be  allowed  to  walk  about 
wearing  it.  A  light  iron  splint  such  as  Thomas's 
may  be  used  instead  of  the  wooden  one. 

If  the  distortion  is  at  all  severe,  a  practical 
difficulty  will  be  met  with  in  applying  and  keeping 
on  the  wooden  splint  :  it  will  be  found  that  the 
splint  slips  round  to  the  antero-external  aspect 
of  the  limb  instead  of  remaining  at  the  outer 
side  ;  when  this  happens  no  traction  is  exerted 
upon  the  knee,  and  the  splint  is  useless.  In 
such  cases',  if  the  iron  cannot  be  obtained,  a 
back  splint  rather  broader  than  the  limb  and  as 
long  as  the  outside  one  should  be  first  applied, 
and  then  the  outside  splint  put  on  with  its  edge 
resting  against  the  edge  of  the  back  splint.  The 
two  splints  can  be  joined  together  so  as  to  make  a 
single  half-box  splint — a  plan  first  used,  we  believe, 
at   the   Victoria    Hospital,    Chelsea.     We    have 

devised  a  splint  which  we  find  efficient  and  satisfactory  (fig.  43). 
a  combined  back  and  outside  splint,  with  a  footpiece  set  at  an  angle 
that  the  outward  rotation  of  the  limb  is  prevented,  and,  by  the  use  of 
elastic  webbing  straps,  the  knee  is  drawn  outwards  towards  the  outside  splint. 
The  letters  indicate  the  position  of  the  webbing  straps  of  which  that  at  E 
should  be  elastic.  We  are  indebted  to  our  friend  Professor  Young  for  the 
drawing  from  which  the  figure  is  taken.  Thomas's  knee  splint  may 
also  be  used  for  these  cases  ;  its  advantages  are  that  the  child  can  get 
about  from  the  first,  and  that  elastic  traction  can  be  employed  with  it ;  its 
disadvantages  that  it  is  somewhat  troublesome  to  get  made  correctly,  except 


It  is 
such 


220  General  Diseases 

at  the  price  of  a  guinea,  and  that  it  is  somewhat  difficult  to  prevent  rotation 
in  it.  Many  other  forms  of  appHance  may  be  bought,  but  those  mentioned 
are  in  our  opinion  the  best.  Whatever  spUnt  is  employed,  complete 
extension  of  the  limb  is  necessary  for  the  apparatus  to  produce  any  effect.^ 
For  bow-leg  it  is  only  necessary  to  apply  the  splint  on  the  inner  side  instead 
of  the  outer,  and  it  is  much  easier  to  manage,  since  there  is  little  tendency 
to  rotation  of  the  splint.  Lateral  curve  of  the  tibia  is  treated  in  the  same 
way,  but  the  splint  need  not  reach  above  the  knee  ;  the  anterior  curve 
requires  a  back  splint  with  a  foot-piece,  and  is  more  troublesome  to  manage, 
pressure  being  difificult  to  apply  without  causing  pain  at  the  heel.  A  simple 
anterior  curve  is,  however,  a  much  less  serious  deformity  than  the  other,  and 
is  much  more  prone  to  improve  without  apparatus. 

Operative  Treatment  of  Rickety  Deformities. — Operation  is  required  in 
patients  in  whom  the  deformity  is  severe,  in  those  who  have  recovered  from 
the  rickety  process  and  whose  bones  are  sclerosed,  and  in  those  who  cannot 
be  well  looked  after  or  submit  to  prolonged  treatment. 

Operative  measures  are  of  three  kinds  :  fracture  after  partial  division  of 
the  bone  with  saw  or  osteotome,  forcible  straightening  without  external  wound, 
and  straightening  after  tenotomy,  &c.  In  cases  of  curvature  in  the  shafts  of 
the  tibia  and  fibula  at  the  lower  part  of  the  leg  in  young  children,  before 
sclerosis  has  occurred,  we  consider  forcible  straightening  a  good  and  simple 
plan,  resulting  in  a  green-stick  fracture  just  at  the  curve.  It  is,  in  any  case 
suitable  for  it,  easily  done  by  taking  the  child's  limb  in  one  hand  just  above, 
and  in  the  other  just  below,  the  deformity,  taking  care  to  have  hold  of  the 
tibia  and  fibula,  and  not  of  the  foot,  otherwise  the  strain  would  come  upon 
the  ankle  joint  ;  the  limb  is  steadily  and  forcibly  bent  straight  by  the  hands  ; 
a  certain  amount  of  jerking  is,  however,  sometimes  useful.  Tenotomy  and 
subsequent  straightening"  in  cases  of  genu  valgum  we  look  upon  as  highly 
objectionable  :  it  weakens  the  joint  and  only  temporarily  straightens  the  limb.'^ 
As  to  forcible  straightening  in  cases  of  genu  valgum,  we  have  strongly 
condemned  it  in  former  editions,  but  having  asked  Mr.  Murray  of  Liverpool 
to  give  his  experience,  he  writes  thus  : 

'  During  the  last  three  years  I  have  practised  somewhat  extensively  a  method  of  treat- 
ment that  was  recommended  by  Professor  Ogston  at  the  Glasgow  Meeting  of  the  British 
Medical  Association — viz.  immediately  and  forcibly  correcting  the  deformity,  and  then 
applying  the  splints.  I  have  thus  straightened  more  than  four  hundred  knock-knees,  and 
have  every  reason  to  be  well  satisfied  with  this  line  of  treatment.  But  in  speaking  of 
osteoclasis  for  genu  valgum,  I  wish  it  to  be  clearly  understood  that  I  practise  it  chiefly  as 
a  substitute  for  splints,  and  consequently  refer  only  to  the  treatment  of  this  deformity  as 
it  occurs  in  quite  young  children,  that  is  to  say,  in  children  under  five  years  of  age,  or  in 
those  a  year  or  two  older  who  are  markedly  rickety. 

'  Many  surgeons,  I  believe,  practise  osteoclasis  for  curved  tibiae,  but  comparatively  few 
do  so  for  knock-knee.  The  objection,  it  is  said,  being  that  in  so  doing  you  produce 
a  separation  of  the  lower  epiphysis  of  the  femur,  and  so  may  interfere  with  the  subsequent 
growth  of  the  limb.  Now  I  have  on  several  occasions  forcibly  straightened  a  knock-knee 
on  one  side  only,  and  have  examined  the  children  eighteen  months  afterwards,  and  found 

1  Hueter  treats  genu  valgum  by  simple  flexion,  and  Little  thinks  well  of  it,  but  suggests 
sitting  a  la  Turque  as  useful. 

^    Vide  Lannelongue,  Le  Bull.  MM.  ;  also  Aiiiials  of  Surgery,  January  1888. 


Osteotomy  221 

absolutely  no  difference  in  the  length  of  the  limbs.  And  further,  at  the  time  of  operation, 
1  examine  for  the  seat  of  fracture,  and  find  that  it  almost  invariably  takes  place  at  a  point 
wlierc  the  lower  end  of  the  femur  joins  the  shaft,  and  quite  an  inch  above  the  epiphyseal 
line. 

'  My  hands  are  the  only  osteoclasts  I  have  ever  used,  and  in  forcibly  straightening 
a  knock-knee  (say  that  of  the  right  side),  standing  to  the  right  of  the  patient,  the  child  of 
course  being  under  chloroform,  1  grasp  the  thigh  firmly  with  my  left  hand  about  two 
inches  above  the  patella,  using  my  index  hnger  supported  by  my  other  fingers  as  a 
fulcrum,  and  hold  the  thigh  perfectly  steady  with  this  hand  ;  then,  with  the  right  hand 
grasping  the  leg  just  above  the  ankle,  gradually  straighten  the  limb,  the  knee  joint  being 
kept  over-extended  the  whole  time. 

'  After  osteoclasis  I  put  the  limb  in  plaster  of  Paris,  which  is  kept  on  for  a  month  ;  the 
plaster  is  then  removed  and  the  child  kept  off  its  feet  for  a  further  period  of  six  weeks, 
after  which  it  is  allowed  to  run  about,  constitutional  treatment  being,  of  course,  adopted 
from  the  first. 

'  There  is  no  doubt  that  in  children  over  four  years  of  age  considerable  force  is  some- 
times necessary  ;  if,  however,  in  attempting  to  forcibly  straighten  a  crooked  bone  one  has 
to  use  so  much  force  as  to  render  it  uncertain  where  the  fracture  will  take  place,  then  you 
had  better  desist  and  perform  an  osteotomy.' 

Mr.  Murray,  in  addition  to  writing  the  above  account,  has  been  good 
enough  to  come  over  and  show  us  his  modus  opei'andi,  and  we  must  admit 
that,  strictly  within  the  Hmitations  of  age  and  rigidity  of  bone  that  he 
mentions,  and  provided  his  exact  method  is  followed,  we  are  convinced  that 
the  operation  is  safe  and  practicable  ;  but  Mr.  Murray's  method  must  be 
absolutely  followed,  and  the  exact  site  of  the  fracture  determined  ;  it  is  not, 
moreover,  every  surgeon  who  has  Mr.  Murray's  skill.  Other  methods  of 
treatment  do  not  require  further  notice. 

Osteotomy. — The  general  principle  of  an  osteotomy  is  to  partially  divide 
with  a  saw  or  chisel  the  shaft  of  the  bone  in  the  neighbourhood  of  the 
deformity  through  a  small  wound,  then  to  complete  the  fracture,  straighten 
the  limb,  and  treat  it  like  an  ordinary  compound  fracture. 

Of  the  various  operations  devised  by  Ogston,  Macewen,  Chiene,  Reeves,  Schede,  and 
others,  for  remedying  genu  valgum,  in  our  experience  that  of  Macew-en  and  the  section 
of  the  femur  above  the  condyles  by  means  of  a  saw  from  the  outer  side  are  the  best.  This 
plan  was,  we  believe,  first  employed  by  our  colleague  Prof  T.  Jones.  We  occasionally 
do  an  Ogston's  operation,  but  supracondyloid  osteotomy  with  a  fine  Adams'  or  keyhole 
saw  is,  we  think,  the  most  generally  useful  method.  Ogston's  plan  should  be  limited  to 
those  cases  where  the  deformity  is  entirely  due  to  condylar  overgrowth.  It  is  very  seldom 
emplo}'ed.  In  the  case  of  osteotomy  of  the  tibia  we  prefer  to  saw  through  the  tibia  and 
fracture  the  fibula  forcibly,  or,  if  that  cannot  be  readily  done,  we  divide  the  fibula  with  an 
osteotome  through  an  incision  on  the  outer  side  of  the  leg. 

After  straightening  the  limb  we  put  it  up  in  a  back  and  side  splint,  inner  or  outer, 
according  to  the  deformity,  or  in  a  Macewen's  splint,  and  leave  it  for  a  week  ;  at  the  end 
of  that  time  we  take  it  down  and  mould  it  accurately  into  position  under  chloroform  : 
the  callus  is  soft  and  moulds  easily  ;  the  limb  is  then  ready  for  a  plaster  of  Paris  splint, 
which  should  be  kept  on  for  three  or  four  weeks  and  then  taken  off,  and  the  limb  well 
rubbed,  the  joints  flexed,  and  then  the  splints  or  the  splint  (fig.  43)  replaced  for  another 
week  ;  after  that  the  child  may  be  allowed  gradually  to  put  his  weight  upon  it.  In  heavy 
children  an  extra  week  should  be  given,  and  a  light  wooden  splint  worn  for  another  month 
or  so.  It  is  a  good  plan  to  put  on  a  Thomas's  knee-splint  after  the  first  month,  or  even 
sooner. 

In  severe  cases  of  tibial  curve,  especially  of  anterior  curvature  and  in  some  of  those 
at  the  upper  part  of  the  leg,  the  deformity  cannot  be  remedied  by  a  simple  section,  but 


222  General  Diseases 

requires  the  removal  of  a  wedge  of  bone  ;  this  is  a  very  much  more  serious  operation,  and 
one  that  we  think  should  not  be  performed  for  the  anterior  curve  alone,  for  besides  its 
severity  it  does  little  to  remedy  the  distortion  unless  a  great  amount  of  bone  is  taken  away, 
and  the  tendo  Achillis  divided  as  well.  This  anterior  curve  is  also  much  less  important 
than  the  lateral  one,  and  has  more  tendency  to  improve  without  operation.  If  osteotomy 
is  required  in  such  a  case,  the  oblique  section  of  Gowan  is  probably  the  best. 

Osteotomy  is  a  simple  operation  in  most  cases,  but  it  has  its  dangers  and  its  mortality. 
The  popliteal  artery  has  three  times  been  wounded,  severe  bleeding  has  also  occurred  from 
the  anastomotica  magna,  death  has  followed  in  some  few  cases,  and  gangrene  of  the  leg 
in  one  at  least — a  case  of  our  own,  in  which  we  removed  a  wedge  from  the  upper  part  of 
the  tibia.  In  this,  our  only  serious  casualty,  no  vessel  was  wounded,  but  either  from 
pressure  of  the  bones  in  their  altered  position,  or  from  the  splints  being  put  on  too  tightly, 
the  limb  had  to  be  amputated  subsequently.  There  is  no  comparison  between  simple 
section  and  excision  of  a  wedge  in  severity.  For  details  of  the  various  operations  we  must 
refer  to  the  orthopsedic  and  general  surgical  works. 

Drilling  holes  in  the  bone  and  subsequent  fracture,  with  modifications  of  this  plan, 
have,  we  think,  no  advantages  over  the  saw  and  osteotome  ;  which  of  these  is  used  is 
nearly  a  matter  of  indifference. 

Multiple  osteotomies,  i.e.  section  of  femur  and  tibia  at  one  or  more  points,  are  some- 
times required  ;  when  this  is  so  we  prefer  to  do  one  at  a  time  on  each  limb,  though  Mac- 
ewen  has  many  times  done  several  with  perfect  success.  Deformities  of  the  fibula  alone 
from  rickets  are  never  important. 

Osteotomy  of  the  femur  with  a  saw  from  the  outer  side  is  best  performed  by  placing 
the  limb  upon  a  sand  pillow,  with  the  knee  slightly  flexed,  and  making  a  puncture  with  a 
large  tenotome  on  the  outer  side  of  the  limb,  just  in  front  of  the  border  of  the  tensor 
vag^nee  femoris,  and  a  finger's  breadth  above  the  level  of  the  adductor  tubercle.  The 
knife  is  then  carried  across  the  limb,  keeping  as  close  to  the  bone  as  possible,  taking  care 
not  to  thrust  it  through  the  skin  on  the  inner  side.  In  this  part  of  the  incision  the  blade 
should  be  held  flat,  i.e.  in  the  same  plane  as  the  surface  of  the  femur;  as  soon  as  the 
inner  side  of  the  limb  is  reached  the  knife  is  turned  with  its  edge  against  the  bone  and 
withdrawn.  It  should  during  withdrawal  be  gently  pressed  against  the  bone  so  as  to 
divide  the  periosteum  and  form  a  track  for  the  saw.  As  soon  as  the  knife  is  taken  out  of 
the  wound  the  narrow  saw  is  thrust  sharply  with  a  jerk  into  the  skin  wound  and  its  point 
made  to  strike  the  femur  ;  it  is  then  carried  readily  over  the  front  of  the  bone  and  its 
point  felt  beneath  the  skin  on  the  inner  side.  The  limb  is  well  steadied  and  the  bone 
sawn  ;  care  being  taken  to  saw  at  right  angles  to  the  axis  of  the  femur.  In  sawing,  the 
hand  should  be  tilted,  so  as  to  divide  mainly  the  outer  and  front  parts  of  the  shaft,  until 
nearly  the  whole  thickness  is  sawn  through.  It  is  a  matter  of  experience  how  far  to  saw 
— usually  about  two-thirds  of  the  way  through  is  sufficient ;  a  useful  guide  is  the  depth 
of  the  saw  from  the  front  of  the  bone  as  felt  through  the  soft  parts.  When  the  bone  is 
nearly  divided  the  saw  is  withdrawn,  the  thigh  steadied  by  the  hand  nearest  the  patient's 
trunk,  and  the  limb  bent  inwards  by  adducting  the  leg  with  the  other  hand.  The  bone 
sometimes  snaps  sharply  and  sometimes  yields :  in  the  latter  case  sclerosis  has  not 
probably  gone  so  far,  and  the  fracture  is  more  or  less  green-stick.  One  of  our  house 
surgeons  remarked  that  the  patient  had  less  pain  after  these  5'ielding  fractures  than  when 
the  division  was  complete,  no  doubt  because  there  was  no  complete  separation  and  less 
mobility  of  the  fragments. 

Should  the  saw  have  been  withdrawn  too  soon,  and  it  is  found  impossible  with  reason- 
able force  to  fracture  the  limb,  it  is  usually  easy  to  reintroduce  the  saw  and  divide  the 
bone  further  :  the  groove  already  made  is  usually  found  without  much  trouble  ;  failing 
this,  the  best  plan  is  to  enlarge  the  opening  and  divide  the  bone  with  an  osteo- 
tome. 

Section  of  the  tibia  is  done  in  the  same  way,  the  puncture  being  made  over  the  anterior 
border  of  the  bone  at  the  line  of  greatest  curvature.  It  is  usually  possible  to  fracture  the 
fibula ;  if  not,  it  should  be  divided  with  an  osteotome  through  an  incision  over  it.  Mac- 
ewen's  operation  we  need  not  describe,  as  for  general  use  we  prefer  the  method  already 
mentioned,  but  we  may  say  it  consists  in  incomplete  section  of  the  femur  with  a  graduated 


Lateral  Curvature  of  the  Spine  223 

osteotome  from  the  inner  side,  through  an  incision  in  the  soft  parts.  His  guides  are  '  a 
Hne  drawn  a  finger's  Ijreadth  above  the  level  of  the  upper  border  of  the  external  condyle, 
and  a  line  drawn  parallel  to  and  half  an  inch  in  front  of  the  tendon  of  the  adductor 
magnus.'  The  point  of  intersection  of  these  lines  is  to  be  the  centre  of  the  incision.  In 
none  of  these  operations  is  any  ligature  or  suture  required,  and  antiseptics  should  be 
rigidly  carried  out.  The  wound  in  the  soft  parts  is  healed  usually  in  a  week,  or  a  point 
of  superficial  granulations  alone  remains,  and  it  is  only  occasionally  that  the  dressings 
require  changing  from  oozing  of  blood.  It  is  well  to  squeeze  all  the  blood  out  of  the 
opening  before  putting  on  the  dressings. 

The  deformity  resulting  from  non-apposition  of  the  fragments  after  these  operations 
gets  modelled  down  after  a  few  months  just  as  in  a  fracture.  Oblique  section  of  the  bone 
as  in  a  splice,  a  plan  suggested  by  Mr.  Gowan,  is  sometimes  worth  trial ;  it  causes  less 
immediate  deformity,  but  is  somewhat  more  difficult  to  manage. 

Xateral  Curvature  of  the  Spine. — This  affection  in  its  most  common 
form  is  a  disease  rather  of  early  aduk  hfe  than  of  childhood,  being  seldom 
found  before  puberty,  hence  only  the  more  important  features  will  be  con- 
sidered here.  There  are,  however,  certain  forms  of  scoliosis  that  belong  to 
childhood  more  particularly  :  such  are  the  rickety  lateral  curvatures  and  those 
due  to  empyema  or  unilateral  limb-shortening,  as  well  as,  of  course,  the  con- 
genital cases.  It  must  be  remembered  that  in  infants  the  normal  curvatures 
of  the  adult  spine  do  not  exist. 

It  is  now  well  recognised  that  the  deformity  is  a  compound  one,  that  there 
is  never  a  pure  lateral  curve  without  rotation,  nor  pure  rotation  without  a 
lateral  curvature,  although  it  may  in  some  cases  require  close  observation  to 
verify  this,  and  the  more  so  that  rotation  conceals  to  a  greater  or  less  extent 
the  deviation  of  the  spinous  processes  by  bringing  them  nearer  the  middle 
line. 

As  soon  as  any  lateral  bending  in  one  segment  of  the  spine  occurs,  two 
things  necessarily  happen  if  the  child  maintains  the  erect  posture  :  first, 
compensatory  curves  must  take  place  in  the  other  parts  of  the  spine  to 
balance  the  primary  curve  and  maintain  equilibrium  ;  next,  the  obliquity  of 
the  articular  processes,  and  in  the  dorsal  region  the  powerful  rotation  action 
of  the  ribs  when  they  are  approximated,  must  result  in  rotation  of  the 
vertebrae  upon  a  vertical  axis.'  Hence  in  a  case  of  lateral  curvature  we 
almost  always  see  compensatory  curves  in  the  opposite  direction,  and  in- 
\ariably  more  or  less  rotation  ;  the  term  rotato-lateral  curvature  is  therefore 
the  more  exact  title.  Scoliosis  is  convenient  as  a  short  synonym.  Scoliosis 
in  children  may  be  the  result  of— 

1.  Congenital  malformation  of  the  spine,  in  which  imperfect  segments 
of  vertebral  bodies  are  intercalated  on  one  side  of  the  spine  only.  (Bland 
Sutton,  '  Med.-Chir.  Trans.'  1884.) 

2.  Congenital  deficiencies  in  the  limbs  of  one  side,  so  that  the  action  of 
the  muscles  and  the  weight  of  the  normal  limb  are  unbalanced. 

Occasionally  scoliosis  is  secondary  to  the  form  of  congenital  torticollis 
which  is  due  to  malposition  in  utero. 

3.  Shortening  of  one  leg  from  any  cause  :  for  instance,  a  flexed,  anchy- 
losed  hip  or  knee  gives  rise  to  shortening  and  compensatory  scoliosis. 

'  Judson  of  New  York  attributes  the  rotation  to  the  fact  that  the  ribs  are  attached  to 
the  spine  behind  the  bodies — -the  latter,  as  it  were,  are  free  in  the  thoracic  cavity,  and  there- 
fore liable  to  rotate,  while  the  spines  form  part  of  the  thoracic  wall. 


224  General  Diseases 

4.  Imperfect  development  or  sinking  in  of  the  chest-wall  on  one  side,  as 
in  atelectasis  or  empyema. 

5.  Muscular  and  ligamentous  weakness  combined  with  faultj^  attitudes. 

6.  Rickets. 

7.  Caries,  especially  if  one  side  of  the  bodies  only  is  involved. 

Various  other  types  of  scoliosis  have  been  described,  but  they  may  all  be 
practically  grouped  under  one  or  other  of  the  above  heads. 

The  mode  of  production  of  rotato-lateral  curvature  by  the  above  causes 
is  obvious  except  in  cases  of  Group  5,  of  which  a  word  or  two  more  must 
be  said.  It  is  usually  stated  that  this  form  of  scoliosis  is  a  disease  of  the 
upper  classes,  and  is  found  in  girls  who  loll  about  or  sit  in  ungainly  attitudes 
for  long  hours,  writing  or  working,  during  their  most  active  period  of  de- 
velopment, while  at  the  same  time  no  sufficient  exercise  is  given  to  their 
muscles.  While  it  is  true  that  weak  spines  or  slight  degrees  of  curvature 
are  often  thus  produced,  the  disease  is  common  enough  among  the  poor, 
and,  as  it  is  usually  neglected  in  its  earlier  stages,  is  seen  in  much  worse 
degrees.  It  is  also  not  rarely  found  in  muscular,  well-developed  people  in 
early  adult  life.  It  is,  moreover,  at  times  produced  in  young  girls  by  carry- 
ing heavy  babies  or  other  burdens  too  great  for  them. 

The  whole  spine  should  in  all  cases  be  carefully  examined  with  the  patient  stripped, 
and  the  back  should  be  inspected  in  different  positions  of  curvature  and  of  the  limbs, 
the  course  of  the  spines  and  the  level  of  the  scapulas  and  iliac  crests  being  noted. 

■  If  a  weak  or  tired  spine  is  examined  with  the  patient  stripped  and 
standing  or  sitting  upright,  it  will  perhaps  be  seen  at  first  to  be  held  fairly 
straight,  but  often  after  a  minute  or  two  the  weight  is  thrown  to  one  side, 
the  lumbar  vertebrae  curve  with  their  convexity  towards  that  side,  and  a 
compensatory  dorsal  curve  appears  with  its  convexity  to  the  opposite, 
usually  the  right,  side,  while  a  slight  alternating  curve  in  the  cervical  region 
is  sometimes  readily  seen.  At  the  same  time  flickering  contractions  of  the 
spinal  muscles  as  they  become  tired  are  often  visible.  In  an  early  case  all 
these  bends  can  be  straightened  out  by  an  effort  of  the  patient,  or  by  bending 
forwards  or  by  lying  down.  If,  however,  the  patient  is  neglected  the  curves 
tend  to  become  permanent,  for  the  weak  muscles  become  contractured  on  the 
concave  side,  the  ligaments  become  shortened,  the  intervertebral  discs  thinned 
and  compressed,  and  the  shape  of  the  vertebral  bodies  and  articular  sur- 
faces at  last  altered.  But  while  this  is  going  on  the  vertebrae  rotate  upon  a 
vertical  axis  so  that  the  bodies  come  to  face  towards  the  convexity  of  the 
curve,  and  the  ribs  become  bent  in  such  a  way  that  there  is  a  sharply  convex 
bend  backwards  close  to  their  angles  on  the  same  side  :  this  produces  a 
prominence  also  on  the  convex  side,  while  in  front,  in  order  as  it  were  to 
reach  the  sternum,  the  ribs  are  usually  more  or  less  flattened  and  straightened 
out.  The  converse  of  all  this  takes  place  on  the  opposite  side  of  the  spine. 
There  is  still  a  further  change  resulting  from  this  :  the  scapula  on  the  convex 
side  is  pushed  out  by  the  bulging  ribs  and  projects  backwards,  while  it  is  raised 
or  lowered  above  the  level  of  its  fellow  according  to  the  exact  seat  of  the 
curve  ;  this  is  so  marked  that  'growing  out  of  the  shoulder'  is  usually  the 
first-noticed  sign  and  the  popular  name  for  the  affection.  The  scapula  on 
the  concave  side  also  often  projects  sharply  backwards  and  towards  the  mid- 


Lateral  Curvature  of  the  Spine 


225 


line,  since  it  cannot  rest  evenly  against  the  flattened  chest  wall  {vide  fig.  44). 
A  projection  of  the  hip  on  one  side  or  the  other  according  to  the  curve  will 
also  be  noticeable. 

All  degrees  of  deformity  may  be  met  with,  from  the  mere  weak  spine,  with 
no  permanent  curves,  but  with  a  tendency  to  collapse  in  any  direction,  to 
deformity,  where  the  ribs  on  one  side  are  overlapping  one  another  and  lying 
within  the  crest  of  the  ilium,  while  the  whole  trunk  is  distorted  and  misshapen. 
Sometimes  an  antero-posterior  curve  (kyphosis)  coexists  with  the  scoliosis, 
and  it  is  very  important  not  to  be  misled  by  this  ;  still  more  important  is  it  to 
remember  that  in  cases  of  caries  there  is  sometimes  a  latei^al  curvature  before 
any  angular  curve  appears  :  this  may 
occur  either  in  caries  of  the  bodies  or,  as 
pointed  out  by  Reeves,  where  there  is 
disease  of  the  articular  processes  or  costo- 
vertebral joints.  The  diagnosis  is  to  be 
made  by  noting  the  rigidity  of  the  spine 
and  usually  the  greater  severity  of  the  pain 
in  the  case  of  caries,  as  well  as  by  the 
history  of  the  patient.  The  exact  position 
of  such  curve  is  by  no  means  constant, 
and,  though  a  curve  convex  to  the  left  in 
the  lumbar  and  convex  to  the  right  in  the 
dorsal  region  is  the  commonest  condition, 
the  lower  curve  may  be  dorso-lumbar  or 
the  sides  may  be  reversed,  and  so  on. 
This,  of  course,  depends  largely  upon  the 
cause  of  the  curvature  ;  thus  in  empyema 
the  amount  and  position  of  the  collapse 
will  determine  the  curve  Sometimes,  es- 
pecially in  rickety  cases,  and  probably  in 
those  due  to  partial  atelectasis,  the  curva- 
ture is  local'and  the  compensatory  curves 
are  so  slight  and  diffuse  as  to  be  nearly 
imperceptible.  In  some  cases  curvature 
of  the  spine  is  to  be  looked  upon  as  com- 
pensatory and  advantageous,  and  not  as 
a  morbid  condition  ;  such  are  slight 
curvatures  which  make  up  for  inequality 

in  the  length  of  the  limbs  and  the  slighter  degrees  of  curve  due  to 
empyema  ;  thus  in  one  case  the  curve  may  help  to  hide  the  deformity  and 
in  the  other  assist  in  filling  up  a  suppui'ating  cavity. 

Aching  pain  of  greater  or  less  severity,  and  a  general  feeling  of  tiredness, 
with  depression  of  spirits  and  tonelessness,  are  the  principal  subjective 
symptoms  of  lateral  curvature.  The  pain  is  usually  in  the  side  and  not  in 
the  back  or  chest  and  abdomen. 

Treatment. — Scoliosis  due  to  congenital  malformation  of  the  spine  itself 
or  to  deficiency  of  an  entire  limb,  as  well  as  that  due  to  collapse  of  the  chest- 
wall  after  empyema  or  severe  atelectasis,  is  necessarily  not  entirely  and  in 
many  cases  not  at  all  remediable,  while  curvature  due  to  rickets,  weakness, 

Q 


Fig.  44. — Lateral  Curvature  of  the  Spine 


226 


General  Diseases 


bad  habits,  or  a  shortened  leg  may  in  its  early  stages  be  entirely  cured  and 
in  almost  any  stage  prevented  from  getting  worse. 

In  any  case  the  aim  must  be  to  first  remove  the  cause  tending  to  increase 
the  deformity,  to  improve  the  general  health,  to  strengthen  the  muscles  and 
ligaments,  and  to  avoid  pressure  and  strain  upon  the  weak  parts.  In  the 
rickety  scoliosis  of  young  children  the  rickets  must  be  treated  and  the  child 
never  allowed  to  remain  sitting  up  for  any  length  of  time  ;  its  general  posture 
must  be  flat  upon  its  back  or  face,  or  upon  its  side,  with  pihows  so  arranged 
as  to  straighten  out  the  curves.  The  principle  is  not  to  keep  the  patient 
lying  down,  which  would  of  course  innoway  strengthen  the  muscles,  but  to  give 


Fig.  45. — Reclining  Board  for  Lateral  Curvature,  with  Extension  Apparatus  for  the  Head  and 
Arms.  The  head  straps  have  been  omitted  for  clearness,  and  only  part  of  the  couch  is  shown. 
Both  head  and  hand  straps  are  fitted  with  india-rubber  accumulators. 


the  parts  just  such  exercise  as  will  make  them  develop,  and  in  the  intervals 
give  them  complete  rest. 

Fresh  air,  friction  to  the  spine,  with  frequent  change  of  position  and  proper 
exercises,  diet  and  medicine,  will  readily  cure  any  case  in  which  there  are  no 
fixed  curves,  while  in  the  more  severe  cases  in  older  children  the  same  treat- 
ment must  be  adopted.  In  an  ordinary  case,  the  result  of  weak  muscles  and 
joints,  and  improper  postures,  the  lines  of  management  are  to  avoid  tiring  the 
muscles  and  ligaments,  and  yet  to  strengthen  them  by  exercise  ;  to  avoid  the 
postures  which  have  produced  the  deformity  ;  to  counteract  their  effect  by 
opposite  positions,  thus  stretching  contractured  muscles  and  ligaments,  &c. 
It  is  impossible  here  to  enter  into  details  of  the  various  exercises  required  or 


Lateral  Ciirvature  of  the  Spine  227 

of  the  different  apparatus  recommended,  but  it  may  be  said  that  in  addition  to 
all  means  of  strengthening  the  health  and  improving  the  tone  of  the  muscles 
— friction,  salt-water  douches,  general  exercise,  and  soon — a  careful  examina- 
tion should  be  made  with  the  child  stripped  entirely  to  see  what  positions 
and  movements  tend  to  correct  the  deformity,  and  these  should  be  made  the 
subject  of  regular  practice  at  intervals  through  the  day.  A  reclining  board 
such  as  that  figured  (fig.  45),  or  some  similar  one,  horizontal  bars,  trapezes, 
dumb-bells,  Sayre's  suspension  apparatus,  and  so  on,  are  all  useful  as  means 
of  strengthening"  the  muscles. 

Regular  walking  exercise  for  frequent  short  periods  should  be  taken,  the 
patient  lying  down  afterwards,  and  constant  watchfulness  to  correct  any 
tendency  to  loll  must  be  observed.  Busch's  plan  of  making  the  patient  lie 
prone,  with  the  chest  and  head  over  the  end  of  a  couch,  then  bending  down- 
wards and  raising  the  front  half  of  the  body  against  gradually  increasing 
resistance,  is  a  good  method  of  exercising  the  spinal  muscles.  Bending 
the  body  forward  with  the  knees  straight  and  trying  to  touch  the  toes  with 
the  hands,  then  recovering  and  bending  backwards  with  the  head  well  thrown 
back  ;  keeping  head  and  shoulders  back  and  leaning  towards  the  side  of 
greatest  convexity,  then  recovering  the  upright  posture  ;  lying  down  with  a 
large  hard  pillow  or  Barwell's  sling  under  the  convexity  of  the  ribs  ;  raising 
the  arm  on  the  concave  side  and  pulling  the  body  up  by  it  by  means  of  a 
horizontal  bar  or  trapeze  ;  all  these  are  good  movements.  For  private 
patients  much  time  is  saved  to  the  surgeon  and  expense  to  the  patient  by 
instructing  a  professed  masseuse  or  gymnast  to  carry  out  such  manipulations 
as  the  surgeon  may  order. 

It  is  a  good  plan  to  let  the  patient  sleep  in  a  Barwell's  sling  or  put  a  hard 
pillow  under  the  convexity  of  the  chest  and  remove  the  one  under  the  head, 
or  substitute  a  thin  one  for  it.  Of  forcible  '  redressement '  we  have  no 
experience,  but  careful  moulding  of  the  deformity  with  the  hands  is  worth 
doing. 

All  spinal  supports  are  to  be  reserved  for  cases  where  the  deformity  is 
extreme  or  rapidly  increasing,  and  must  be  used  with  the  greatest  caution 
and  never  relied  upon  except  in  conjunction  with  the  exercises  and  other 
means  already  indicated.  As  a  means  of  treatment  alone  they  are  as  harm- 
ful as  they  are  wrong  in  principle.  No  cases  of  lateral  curvature  must  ever 
be  given  up  to  the  care  of  an  apparatus  maker.  For  details  as  to  spinal 
supports,  modes  of  measuring  the  deformity  &c.  the  works  of  Reeves  and 
others  may  be  consulted,  but,  as  a  rule,  the  less  supports  are  used  the  bettei'. 

Antero-posterior  Curvature. — Occasionally  cases  of  antero-posterior 
curvature  (kyphosis)  are  met  with  in  children,  both  in  infants  and  in  those 
of  older  growth.  These  must  be  distinguished  from  the  common  rickety 
kyphosis.  They  give  rise  to  an  appearance  closely  resembling  the  stooping 
and  bent-back  of  old  age,  and  may  be  mistaken  for  cases  of  caries.  Absence 
of  rigidity  and  pain,  and  of  evidence  of  rickets  will  usually  enable  these  cases 
to  be  recognised,  but  it  is  well  to  watch  them  closely  for  a  considerable  time 
before  assuming  that  there  is  certainly  no  caries.  Exercises  and  a  suitable 
light  steel  support  are  the  best  means  of  treatment. 

Note. — The  subject  of  'Flat-foot'  is,  for  convenience  sake,  considered  in  the  chapter 
on  '  Club-foot. ' 

Q2 


228  Tuberculosis 


CHAPTER   XIII 

TUBERCULOSIS 

Etiology. — To  become  tuberculous  an  individual  must  be  infected  by  the 
Bacillus  tuberculosis,  and  at  the  time  of  infection  must  present  somewhere  in 
his  body  a  suitable  soil  for  the  propagation  of  the  organism. 

There  seems  little  doubt  that  anyone  living  under  present  conditions  in 
a  large  city  has  plenty  of  chances  of  becoming  tuberculous,  and  if  he  does 
not  become  so,  it  is  not  so  much  from  lack  of  opportunity  as  from  his 
tissues  being  incapable  of  playing  the  part  of  host.  There  is  reason  to 
believe  that  the  dust  of  dwellings  is  frequently  the  carrier  of  the  germs,  and 
that  the  bacilli  gain  entrance  into  the  lungs  by  the  inspired  air.  There  is 
strong  evidence  to  show  that  the  bacilli  frequently  find  their  way  into  the 
alimentary  canal  by  means  of  milk  taken  as  food.  The  infant  may  also 
become  infected  by  its  habit  of  putting  all  sorts  of  things  to  its  mouth,  to 
say  nothing  of  the  '  comfort '  which  is  alternately  on  the  floor  and  in  the 
mouth. 

The  relative  importance  of  the  'soil'  as  compared  with  the  'seed'  has 
been  much  discussed  In  past  times  before  Koch's  discovery,  the  tubercular 
or  strumous  diathesis  derived  from  inheritance  was  looked  upon  as  playing 
a  very  important  part  in  predisposing  to  tuberculosis.  That  it  does  play  an 
important  part  is  certain,  as  experience  teaches  that  a  vulnerability  or  a  pre- 
disposition to  become  tuberculous  runs  in  families,  and  indeed  the  same 
is  true  of  measles,  scarlet  fever,  and  other  infectious  diseases.  But  it  is 
not  always  easy  to  distinguish  between  the  influence  exerted  by  heredity 
and  the  influence  exerted  by  bad  food,  exposure  to  cold,  bad  air,  and  by 
other  conditions  which  lower  vitality  and  render  the  individual  a  ready  prey 
when  infected.  There  can  be  no  doubt  that  some  infectious  diseases,  such 
as  measles  and  whooping  cough,  predispose  to  tuberculosis  by  rendering 
certain  groups  of  lymphatic  glands,  as  the  cervical  and  bronchial,  for  instance, 
a  suitable  soil  for  the  propagation  of  the  specific  bacilli. 

The  age  of  the  individual  appears  to  have  an  important  influence.  The 
foetus  very  rarely  suflfers  from  tuberculosis,  and  newly  born  infants  rarely  suffer. 
Newly  born  calves  are  apparently  rarely  attacked,  though  born  of  mothers 
affected  with  well-marked  tubercular  disease.  Tuberculosis  is  not  a  common 
disease  in  infants  under  six  months  of  age  ;  it  is  rare  to  find  infants  under  this 
age  suffering  from  mesenteric  disease,  tuberculous  meningitis,  or  tuberculous 
disease  of  glands  or  bones.  The  disease  is  more  common  between  the  ages 
of  six  months  and  a  year,  but  after  a  year  old  and  onwards  it  becomes 


Pathology  229 

exceedingly  common.  With  the  exception  perhaps  of  children  under  a  year 
old,  the  susceptibility  to  tubercular  disease  is  greater  during  early  than 
adult  life.  It  cannot  be  said  with  any  accuracy  what  proportion  of  our  child 
population  suffers  from  tuberculosis,  and  statistics  cannot  be  of  much  value 
on  account  of  the  difficulty  of  diagnosing  tuberculosis  of  the  internal  organs, 
especially  in  the  milder  forms. 

Pathology. — It  is  safe  to  say  that  of  all  the  organs  of  the  body,  the 
lymphatic  glands,  especially  those  which  drain  mucous  membranes,  are  the 
most  likely  to  be  infected  with  tubercle  during  early  life.  The  groups  of  glands 
most  often  affected  are  the  cervical,  bronchial,  and  mesenteric  glands.  The 
cervical  group  drain  the  mouth  and  pharynx,  and  assuming  that  the  bacilli 
are  arrested  in  the  mouth  or  nose  from  air  inspired  or  food  taken,  they  may 
enter  the  lymphatics  and  become  arrested  in  the  cervical  glands,  and  if  the 
soil  is  favourable  will  develop  here.  Extension  may  take  place  over  a  wide 
area,  the  local  glands  becoming  affected,  and  later  possibly  distant  parts. 
In  the  same  way  if  the  bacilli  enter  the  bronchial  tubes  they  are  probably 
arrested  in  the  bronchial  glands.  Tuberculosis  of  the  mesenteric  glands 
arises  in  a  similar  manner,  from  bacilli  entering  the  alimentary  canal  in 
milk  or  other  food.  In  the  vast  majority  of  cases  it  is  likely  that  the  route 
taken  by  the  infective  germs  is  by  the  cervical,  bronchial,  or  mesenteric 
glands.  While  in  a  large  number  of  cases  local  foci  are  first  formed  in 
these  glands  and  distant  foci  develop  secondarily,  yet  this  is  apparently  not 
always  so,  as  it  is  presumably  quite  possible  for  the  bacilli  to  find  no  resting 
place  in  the  glands,  but  pass  through  them  to  some  distant  part,  as  for 
instance  the  cerebellum  or  the  epiphysis  of  a  long  bone.  In  many  cases  the 
tuberculous  process  spreads  by  direct  contact  ;  thus  frequently  the  roots  ot 
the  lungs  ai'e  invaded  by  extension  from  tubercular  bronchial  glands  which 
accompany  the  bronchi  into  the  lungs.  A  lung  is  sometimes  affected 
secondarily  by  contact  with  the  caseating  body  of  a  dorsal  vertebra. 
Tubercular  peritonitis  often  arises  from  contact  with  caseous  mesenteric 
glands  or  contact  with  tuberculous  intestines.  Apart  from  contact  the 
lymphatics  are  doubtless  the  principal  channels  by  which  the  bacilli  are 
conveyed  from  one  part  of  the  body  to  another.  It  seems  likely,  however, 
that  in  some  instances  the  micro-organisms  are  distributed  by  the  blood- 
vessels. It  seems  probable  that  in  a  tuberculous  meningitis  secondary,  as  it 
often  is,  to  caseous  bronchial  glands,  the  infective  bacilli  have  travelled  by 
the  blood-vessels.  Some  authorities,  however,  do  not  believe  in  this  method 
of  dissemination. 

Besides  the  lymphatic  glands,  tuberculous  disease  of  bone  is  exceedingly 
common  during  early  life,  as  for  instance  caries  of  the  spine,  chronic  hip 
disease,  chronic  osteo-myelitis  of  the  small  bones  of  the  hands  and  toes. 
Dactylitis  is  very  frequently  associated  with  '  strumous  nodes '  or  '  cold ' 
subcutaneous  abscesses.  What  determines  the  growth  of  tubercle  in  a 
particular  body  of  a  vertebra  or  the  epiphysis  of  a  hip  ?  Presumably  the  infec- 
tive germs  have  entered  the  system  by  the  ordinary  channels,  but  why  is  a 
particular  spot  selected  ?  It  is  impossible  to  say  why  that  particular  spot 
should  be  a  suitable  soil,  but  it  is  by  no  means  unlikely  that,  in  some  instances 
at  any  rate,  an  injury  followed  by  some  chronic  inflammation  may  be  the 
predisposing  cause.     In  tuberculous  disease  of  the  bones  in  relation  to  the 


230 


Tuberculosis 


tympanic  cavity,  suppuration  perhaps  predisposes  and  the  infection  enters 
from  the  throat. 

With  regard  to  the  internal  organs,  there  is  strong  evidence  to  show  that 
the  lungs  are  more  frequently  affected  than  any  other  internal  organs,  but  at 
the  same  time  it  must  be  said  that  during  early  life  tubercular  lesions  are 
much  more  widely  distributed  throughout  the  body  than  they  are  in  adult 
life.  A  general  tuberculosis  in  which  lungs  and  abdominal  organs  share  is 
very  common.  In  155  cases  of  tuberculosis  dying  in  the  Manchester 
Children's  Hospital,  it  was  found /c>.y/  mortem — 

The  lungs  were  affected  in      .         .         .         .         141  or  91  per  cent 
,,    bronchial  glands  were  affected  in    .         .         122  or  78       „ 
„    mesenteric  glands  ,, 

„    liver 


spleen 

intestines 

brain 

peritoneum 

kidney 


loi  or  65 
98  or  63 
86  or  55 
85  or  55 
72  or  46 
69  or  44 
65  or  40 


A  careful  examination  of  these  cases  was  made  with  a  view  to  try  to 
come  to  a  conclusion  as  to  the  route  by  which  the  infection  had  entered  the 
system.  We  came  to  the  conclusion  that  in  at  least  50  per  cent,  of  the  cases 
the  bronchial  glands  or  lungs  were  first  affected  ;  that  in  12  or  13  per  cent, 
the  abdominal  organs  were  primarily  affected,  making  it  probable  that  the 
intestines  and  mesenteric  glands  had  been  affected  by  food  or  milk  contain- 
ing" tubercle  bacilli.  In  the  remainder  of  the  cases  the  lesions  were  so 
abundant  and  widespread,  that  it  was  impossible  to  say  which  were  the 
earliest  foci.  In  some  cases  the  cervical  glands  were  caseous  or  cretaceous. 
We  must  bear  in  mind  that  the  figures  just  given  only  refer  to  cases  of 
tuberculosis  dying  of  meningitis  or  from  exhaustion  the  outcome  of  hectic 
fever,  malnutrition  or  diarrhoea.  They  are  no  certain  guide  to  the  numerically 
much  larger  number  of  cases  of  local  tuberculosis  which  do  not  die  but  in 
whom  the  tubercular  process  gradually  comes  to  an  end.  A  large  proportion 
of  children  suffering  from  tubercular  peritonitis  recover,  the  lesions  probably 
never  being  widespread.  In  a  large  proportion  of  children  with  caseous 
glands  in  the  neck,  or  bone  tuberculosis,  the  lesions  remain  local  and 
recovery  takes  place.  The  figures,  however,  certainly  point  to  the  frequency 
with  which  the  infection  enters  the  system  by  the  inspired  air.  If  the  bacilli 
enter  the  bronchi,  they  are  arrested  in  a  cul-de-sac  and  are  under  favourable 
conditions  for  entering  the  lymphatics,  while  if  they  enter  the  alimentary 
canal  they  are  likely  to  be  passed  along  with  the  liquid  contents  of  the 
intestines.  There  is,  however,  strong  evidence  that  infection  does  take 
place  from  the  intestines,  as  in  some  of  our  cases  the  lesions  were  confined 
entirely  to  the  abdominal  organs.  Inasmuch  as  a  considerable  proportion  of 
cases  of  tubercular  peritonitis  recover,  it  is  possible  that  the  12  to  13  per 
cent,  given  above  as  the  proportion  of  cases  infected  through  the  ali- 
mentary canal  does  not  by  any  means  adequately  represent  the  proportion 
so  infected. 

One   point  is  worthy  of  remark,  and  that  is  with  regard  to  the  different 


Pathology  231 

degrees  of  malignancy  exhibited  by  tuberculous  processes.  Compare  for 
instance  an  acute  miliary  tuberculosis  running  a  course  of  a  few  weeks,  and 
a  tuberculosis  of  a  cervical  gland  or  patch  of  lupus  which  shows  but  little 
tendency  to  spread  or  at  least  spreads  very  slowly.  There  is  an  immense 
difference  between  the  rate  of  progress  in  some  cases  of  phthisis  and  others. 
It  is  clear,  inasmuch  as  the  tubercular  process  is  spread  by  contact,  that  the 
location  of  the  lesion  is  important  in  regard  to  prognosis.  Thus  a  bronchial 
gland  surrounded  by  lung  is  a  far  greater  danger  to  the  individual  than  a 
caseous  cervical  gland.  It  is  perhaps  difficult  to  say  how  far  a  rapid  or  a 
slow  process  is  dependent  upon  the  bacilli  themselves,  whether  they  are  of  a 
malignant  or  mild  type,  or  whether  it  is  a  question  of  soil  alone.  In  the  old 
clays  the  mild  type  or  slowly  progressing  process  in  which  caseation  slowly 
took  place  was  not  recognised  as  tubercular,  but  was  designated  strumous  ; 
while  the  more  acute  type  represented  by  the  '  grey  granulation '  was 
essentially  a  tuberculosis.  To  become  strumous  was  not  a  very  serious 
affair  ;  to  become  tuberculous  meant  a  death  certificate  at  no  distant  date. 
To-day  we  recognise  that  strumous  processes  are  slowly  progressing  tuber- 
culous processes,  and  as  such  are  in  danger  of  involving  important  organs  ; 
while,  on  the  other  hand,  we  know  that  tuberculosis  of  the  lungs  and 
abdominal  organs  may  at  almost  any  stage  become  arrested,  and  that  a  large 
number  of  cases  of  local  tuberculosis  end  by  complete  recovery. 

Practically  there  is  nothing  to  be  gained  by  the  use  of  the  word  struma 
or  scrofula,  nor  of  the  several  '  types '  associated  with  strumous  disease. 
While  tuberculous  disease  may  make  its  appearance  in  the  unhealthy,  or  in 
those  in  whom  there  is  a  family  history  of  tubercle,  yet  it  constantly  crops 
up  in  those  who  are  apparently  in  perfect  health,  and  in  children  where  there 
is  no  history  whatever  of  any  family  tuberculous  disease. 

It  is  unnecessary  for  us  to  say  anything  respecting  the  bacillus  of 
tubercle,  its  appearances,  or  methods  of  cultivation,  or  to  describe  the  histo- 
logical appearances  presented  by  tubercular  lesions.  We  will,  however,  give 
a  short  summary  of  the  differences  which  distinguish  tuberculosis  in  child- 
hood from  that  of  adult  life. 

1.  Frequency  with  which  the  lymphatic  glands  are  affected  in  children. 

2.  Frequency  of  tuberculous  lesions  of  bone  and  subcutaneous  tuberculous 
abscesses. 

3.  The  frequency  with  which  the  abdominal  organs,  peritoneum,  intestines, 
and  mesenteric  glands  are  affected. 

4.  The  frequency  with  which  tuberculous  meningitis  and  caseous  lesions 
of  the  brain  occur. 

5.  The  frequency  with  which  tuberculosis  of  the  lungs  begins  at  the  roots 
by  infection  from  the  bronchial  and  pulmonary  glands. 

The  student  who  attends  the  in-patient  and  out-patient  departments  of  a 
children's  hospital,  and  whose  opportunities  have  been  hitherto  the  study  of 
tuberculosis  as  it  affects  adults  rather  than  children,  will  be  struck  with 
some  of  the  differences  as  just  summarised.  The  form  of  tuberculosis  of 
adults  which  is  most  common  is  a  tuberculous  disease  of  the  lungs,  proceed- 
ing from  apex  to  base.  Among  children  he  will  see  a  large  number  suffering 
from  tubercular  cervical  glands,  spinal  disease,  hip  disease,  dactylitis,  sub- 
cutaneous tubercular  abscesses.     He  will  probably  note  more  cases   com- 


232  Tuberculosis 

mencing  with  abdominal  tuberculosis  than  pulmonary  tuberculosis,  and  he  will 
frequently  come  across  tuberculous  meningitis  and  tuberculous  tumours  of 
the  brain.  He  cannot  fail  to  note  also  the  large  number  of  children  who 
completely  recover  from  tuberculous  disease. 

For  the  most  part  tuberculous  disease  will  be  found  described  in  the 
chapter  devoted  to  the  diseases  of  various  organs  ;  we  will  describe  here  acute 
and  chronic  general  tuberculosis. 


Acute  IMCiliary   Tuberculosis 

Acute  miliary  tuberculosis  is  perhaps  commoner  in  early  life  than  it  is  in 
after  years  ;  it  occurs  at  all  ages  during; childhood,  though  it  is  rare  before 
the  end  of  the  second  year.  Like  tuberculous  meningitis,  with  which  it  is 
often  associated,  it  usually  supervenes  in  children  already  tubercular,  and 
occurs  but  rarely  in  children  who  up  to  the  time  of  falling  ill  had  been  in 
robust  health.  There  is  usually  a  history  of  more  or  less  ill  health  for  some 
time  previous  to  the  attack  ;  there  is  a  history  perhaps  of  whooping  cough 
or  measles  some  months  before,  which  has  left  the  child  weak,  and  from 
which  it  has  never  really  recovered.  Sometimes  the  symptoms  of  a  tuber- 
culosis of  the  lungs  or  abdomen  are  unmistakably  present,  and  then  acuter 
symptoms  supervene  which  mark  the  onset  of  the  miliary  form  of  the 
disease. 

Acute  miliary  tuberculosis  occurs  usually  in  two  forms  :  the  '  typhoid 
form,'  so  called  because  it  is  apt  to  simulate  enteric  fever,  and  the  broncho- 
pneumonic  form,  in  which  the  symptoms  present  are  those  of  acute  pneu- 
monia, the  latter  being  set  up  by  the  presence  of  miliary  tubercle. 

Symptoms. — In  the  typhoid  form  the  commencement  is  usually  insidious, 
and  is  usually  preceded  by  a  period  of  ill  health,  during  which  time  the  child 
has  been  noticed  to  waste,  to  be  feverish  at  night,  to  cough,  and  not  infre- 
quently to  suffer  from  diarrhoea  or  pass  slimy,  unhealthy-looking  stools.  The 
child  is  languid,  irritable  ;  its  appetite  is  very  uncertain,  and  it  cares  but  little 
for  its  toys.  Often  there  are  decided  signs  of  intestinal  catarrh  ;  the  appe- 
tite is  completely  lost,  the  tongue  is  coated,  and  the  abdomen  distended.  An 
examination  of  the  chest  may  give  no  decided  result,  or  only  some  rhonchi 
may  be  heard,  and  there  may  be  no  very  decided  cough.  In  this  stage  if  the 
symptoms  are  acute,  the  resemblance  to  an  irregular  attack  of  enteric  fever 
is  very  close,  especially  if  rose  spots  resembling  those  of  typhoid  are  presen.t, 
as  is  sometimes  the  case.  The  diagnosis  is  especially  difificult/4jji*>^iig 
children  of  three  or  four  years  of  age,  who  are  perhaps  very  irrftaltle  and 
resist  any  examination  of  the  chest  or  abdomen,  the  difficulty  being  to  dis- 
tinguish acute  miliary  tuberculosis  from  enteric  or  subacute  intestinal  catarrh 
with  some  patches  of  broncho-pneumonia.  A  careful  and  continuous  record 
of  the  temperature  is  important  ;  the  temperature  should  be  taken  morning, 
afternoon,  and  evening  ;  the  variations  are  usually  considerable,  sometimes 
varying  from  99°  to  104°  F.,  the  highest  being  usually  at  4  or  5  P.M.  Too 
much  stress,  however,  must  not  be  laid  on  an  intermittent  temperature  with 
considerable  flights,  as  in  some  children  a  patch  of  broncho-pneumonia 
without  marked  physical  signs  will  be  accompanied  by  a  striking  intermittent 
temperature,  and,  moreover,  we  have  seen  a  case  of  miliary  tuberculosis 


Miliary   Tuberculosis  233 

when  the  temperature  only  reached  101-5°  or  102°  in  the  afternoon  or  evening. 
Enlargement  and  tenderness  of  the  spleen  maybe  present  in  an  early  stage; 
in  some  cases  there  is  a  marked  feeling  of  hardness  about  it.  In  one  of  our 
cases  rigors,  with  enlargement  of  the  spleen  and  an  intermittent  temperature, 
suggested  malaria,  but  the  case  turned  out  to  be  acute  tuberculosis. 

Sooner  or  later,  mostly  in  the  course  of  a  week  or  two,  more  characteristic 
symptoms  declare  themselves.  There  is  a  dry  hacking  cough,  especially 
troublesome  at  night  ;  some  crepitation  or  loose  rales  are  heard  at  the 
apices,  roots,  or  bases  of  the  lungs,  and  not  infrequently  a  sub-tympanitic  or 
high-pitched  note  may  be  elicited  on  percussion,  or  perhaps  there  may  be 
signs  of  fluid  at  one  or  both  bases,  with  a  pleuritic  rub.  In  some  cases  there 
is  marked  dyspnoea,  out  of  proportion  to  the  pulse-rate  and  fever  ;  it  is 
caused  by  the  presence  ot  miliary  tubercles  scattered  through  the  lungs,  with 
perhaps  some  disseminated  emphysema  or  broncho-pneumonia.  The  hectic 
continues,  and  probably  sooner 
or  later,  in  the  majority  of 
cases,  cerebral  symptoms,  due 
to  meningitis  or  the  softening  of 
the  brain  which  accompanies  it, 
supervene. 

One  of  the  most  important 
physical  signs  which  may  be 
present  is  that  of  miHary  tu- 
bercles in  the  choroid  ;  the  dis- 
covery of  these  may  not  infre- 
c[uently  clear  up  the  diagnosis 
of  a  doubtful  case.  Unfortunately 
the  restlessness  and  irritability 
of  children  suffering  from  tuber- 
culosis often  render  it  impossible 
to  make  a  thorough  ophthalmo- 
scopic examination.  The  tuber- 
cles appear  as  small,  rounded, 
yellowish  bodies,  scattered  about  the  fundus  ;  one  or  more  may  be  seen  near 
the  disc,  but  usually  they  are  eccentrically  seated  :  five  or  six  may  often  be 
counted.  Often  a  branch  of  a  retinal  artery  or  a  vein  may  be  seen  to  cross 
in  front  of  one.  They  appear  very  rapidly,  being  apparently  formed  in 
the  course  of  a  few  days  ;  if  there  is  tubercular  meningitis,  the  disc  may  be 
swollen  and  indistinct. 

In  a  case  recorded  by  Proebsting  the  detection  of  tubercular  bacilli  in  the 
urine  decided  the  diagnosis  of  a  doubtful  case  in  favour  of  miliary  tuber- 
culosis. In  this;-:|nstance  the  miliary  tuberculosis  was  secondary  to  chronic 
tuberculosis  of  the  kidney. 

The  duration  ^f  the  disease  varies,  in  some  cases  being  short,  often  only 
thrs,e  weeks  ;  in  others,  perhaps  the  majority,  it  is  longer,  the  patient  linger- 
ing for  six  or  seven  weeks.  The  supervention  of  tubercular  meningitis  or 
bron'iiho-pneumonia  quickly  brings  the  end. 

Tl|ef.  broncho-pneumonic  form  occurs  most  often  in  children  from  two 
to  "five'yea:rs  of  age,  and  in  the  vast  majority  of  cases  is  mistaken  for  an  attack 


Fig.  64. — Miliary  Tubercles  of  the  Choroid  ;   slight 
optic  neuritis.     (From  a  drawing  by  P.  H.  Mules.) 


234  Tuberculosis 

of  acute  broncho-pneumonia.  There  is  often  a  history  of  measles  or  whooping 
cough  shortly  before  the  attack,  and  probably  there  has  been  a  period  of 
ill  health  with  wasting.  The  symptoms  are  precisely  those  of  acute  broncho- 
pneumonia ;  there  is  fever,  dyspnoea  ;  rales  or  crepitation  are  heard  over  an 
extended  area  of  lung,  with  more  or  less  impaired  resonance  over  a  corre- 
sponding area.  The  disease  usually  runs  its  course  in  about  ten  days  to  two 
weeks,  death  resulting  from  exhaustion  and  more  or  less  asphyxia.  The 
family  history  or  previous  health  may  suggest  tuberculosis  in  any  given  case, 
but  no  definite  diagnosis  of  tuberculous  broncho-pneumonia  can  be  made 
unless  tubercles  are  seen  in  the  choroid.  The  supervention  of  meningitis 
suggests  tubercle,  but  a  simple  meningitis  may  accompany  or  follow  broncho- 
pneumonia, especially  in  infants  and  young  children. 

It  must  be  borne  in  mind  that  acute  or  at  least  subacute  general  tuber- 
culosis, which  is  not  of  the  miliary  form,  may  occur  disseminated  through  all 
the  organs.  A  tuberculosis  may  run  a  course  of  six  weeks  to  two  months, 
accompanied  by  hectic  and  wasting,  and  the  principal  lesions  found  post- 
mortem are  not  miliary  tubercles,  though  these  may  be  present,  but  ragged 
cavities  in  the  lungs,  caseous  bronchial  and  mesenteric  glands,  and  caseous 
masses  in  the  liver,  spleen,  and  kidneys.  In  these  cases  the  diagnosis  may 
be  difficult  or  impossible  for  the  first  few  weeks,  but  careful  examinations  of 
the  apices  of  the  lungs  will  generally  decide  the  question. 

Diagnosis. — Acute  miliary  tuberculosis  may  be  confounded  with  acute 
disseminated  tuberculosis,  in  which  the  tubercular  growth  takes  the  form  of 
caseous  nodules  or  other  forms  rather  than  the  typical  purely  miliary  form. 
The  diagnosis  is  of  very  little  importance  except  as  regards  the  acuteness 
of  the  case,  the  miliary  form  being  necessarily  the  most  rapidly  fatal. 
Both  miliary  tubercles  and  caseous  infiltrations  may  be  found  in  the  same 
organ.  Acute  miliary  tuberculosis  may  be  mistaken  for  typhoid  fever, 
subacute  intestinal  catarrh,  acute  broncho-pneumonia,  acute  endocarditis,  and 
pyaemia,  and  we  may  add  influenza  when  the  attack  is  prolonged,  as  it  some- 
times is  for  many  weeks. 

In  making  a  diagnosis  the  family  and  personal  history  is  of  great  im- 
portance ;  if  other  children  or  older  members  of  the  family  have  died  of 
tuberculous  disease,  the  probabilities  in  a  doubtful  case  will  naturally  be  in 
favour  of  tubercle  ;  but  it  must  not  be  forgotten  that  apparently  healthy 
children  with  a  good  family  history  will  sometimes  die  of  acute  tuberculosis. 
A  history  of  a  recent  attack  of  measles  or  whooping  cough  would  be  sug- 
gestive, but  children  with  such  a  history  may  of  course  have  typhoid  or 
any  other  acute  attack.  There  cannot  be  much  difficulty  in  distinguishing  a 
typical  attack  of  typhoid  fever  from  one  of  acute  tuberculosis,  but  it  may  be 
quite  impossible  to  make  a  diagnosis  between  an  irregular  and  an  erratic 
attack  of  typhoid  and  tuberculosis.  In  both  diseases  there  may  be  some 
looseness  of  the  bowels,  abdominal  distension,  and  intermittent  fever ;  in 
both  the  spleen  may  be  enlarged.  It  is  only  by  having  the  patient  under  ob- 
servation for  some  days,  and  frequently  examining  the  chest,  that  a  dia- 
gnosis can  be  made.  A  short  hacking  cough,  hectic  fever,  great  variations 
of  temperature,  dyspnoea  out  of  proportion  to  the  temperature,  and  crepita- 
tion heard  in  the  chest,  would  favour  the  diagnosis  of  acute  tuberculosis. 
Any  cerebral  symptoms,  such  as  convulsions,  squinting,  drowsiness,   mus- 


Miliary   Tuberculosis  235 

cular  rigidity,  or  paresis  suggesting  meningitis,  also  favour  the  diagnosis  of 
this  disease. 

Some  cases  of  broncho-pneumonia,  where  the  distribution  is  patchy  and 
the  temperature  markedly  intermittent,  closely  simulate  acute  tuberculosis, 
and  for  a  few  days  or  a  week  a  certain  diagnosis  cannot  be  arrived  at.  It 
is  only  perhaps  when  the  pneumonia  clears  up,  and  the  temperature  tends 
to  normal,  that  the  suspicions  of  tuberculosis  are  relieved. 

In  acute  endocarditis  the  temperature  is  apt  to  be  hectic,  and  in  the 
absence  of  a  bruit  the  diagnosis  may  be  difficult.  The  presence  of  a  bruit 
would  necessarily  prove  the  case  to  be  almost  certainly  acute  endocarditis, 
in  spite  of  it  resembling  tubercle  in  other  ways. 

Prognosis. — If  the  diagnosis  of  acute  miliary  tuberculosis  can  be  definitely 
made,  the  prognosis  cannot  be  otherwise  than  exceedingly  grave.  There 
can  be  little  doubt  that  in  a  few  cases,  in  an  early  stage,  before  the  miliary 
tubercles  are  widely  extended,  recovery  may  ensue  ;  but  when  the  tubercu- 
losis has  become  general  very  little  hope  indeed  can  be  entertained. 

Morbid  Anatomy. — The  amount  of  emaciation  present  depends  upon  the 
chronicity  of  the  case  ;  we  have  seen  at  the post-jnorteni  cases  in  which  there 
was  a  fair  amount  of  subcutaneous  fat  in  those  who  had  died  of  acute  miliary 
tuberculosis.  On  opening  the  chest,  the  lungs  are  found  to  be  in  a  condition 
of  deep  inspiration,  almost  as  if  they  had  been  injected  with  some  fluid  from 
the  trachea,  while  miliary  tubercles  are  seen  on  the  surface  or  beneath  the 
pleura.  On  section  the  lungs  are  found  stuffed  with  miliary  tubercles,  of  a 
grey  colour  and  the  size  of  millet  seeds,  usually  so  crowded  that  not  a  cubic 
inch  in  the  whole  lungs  will  be  found  free.  They  are  mostly  more  crowded 
at  the  apex  than  at  the  base.  Caseating  or  suppurating  bronchial  glands 
are  almost  certainly  present.  Frequently  miliary  tubercles  are  present  in 
the  glands.  Miliary  tubercles  will  be  found  crowded  together  in  the  liver, 
spleen,  kidneys,  and  serous  membranes — frequently  also  in  the  choroid, 
and  on  the  vessels  at  the  base  of  the  brain. 

In  other  less  acute  cases  caseous  masses  and  peribronchial  tubercles  may 
be  found  in  the  lungs,  and  may  be  associated  with  more  or  less  miliary  tuber- 
culosis. It  is  curious  to  note  that  many  observers  have  failed  to  find  the 
tubercular  bacilli  in  miliary  tubercles,  and  others  have  found  granular  masses 
suggestive  of  spores  (Biedert,  Ribbert,  Malassez,  and  Vignal). 

Treatment. — If  the  diagnosis  of  acute  miliary  tuberculosis  can  be  made 
with  certainty,  little  can  be  hoped  for  from  the  administration  of  drugs.  The 
treatment  must  in  such  cases  be  a  treatment  of  symptoms.  If  the  tempei^a- 
ture  takes  high  excursions  towards  evening,  quinine,  antipyrin,  or  phenacetin 
may  be  given  to  anticipate  the  rise,  and  the  patient  packed  or  sponged  with 
cold  water  to  reduce  it.  The  troublesome  cough  may  be  relieved  by  codeia 
jelly  or  minute  doses  of  opium.  The  strength  should  be  maintained  by  a 
liberal  diet  of  beef  tea,  soups,  port  wine.  Burgundy  ;  extract  of  malt  and  cod 
liver  oil  should  also  be  given.  Iodoform  sometimes  appears  to  be  useful, 
though  it  can  hardly  be  said  to  have  any  power  in  arresting  the  disease  ;  it 
may  be  given  in  powder  with  sugar  in  half-  to  two-grain  doses.  The  com- 
bination of  digitalis  and  bark  has  appeared  to  us  to  produce  a  tempoi-ary 
improvement,  but  any  permanent  change  for  the  better  cannot  be  looked 
for.     Creasote  and  guaiacol  have  also  been  used. 


236  Tuberculosis 

Scrofula  and  Tuberculosis 

Liability  to  Tuberculosis. — In  certain  children  there  is  a  characteristic 
tendency  to  inflammation  from  trivial  causes  ;  this  inflammation  is  apt  to  occur 
in,  or  rather  pick  out,  the  lymphatic  tissues  ;  once  aroused,  it  tends  to  spread, 
attacking  often  distant  parts  of  the  body.  If  its  course  is  slow,  the  foci  of 
disease  tend  to  become  caseous  ;  once  started  the  progress  seldom  stops,  or 
rather,  though  it  may  be  arrested  for  a  time,  it  is  apt  to  be  set  going  again 
by  slight  causes,  even  after  long  intervals  of  time.  This  tendency  is  found  to 
run  in  families,  some  members  showing  one  form  of  lesion,  some  another. 
At  times  different  forms  occur  at  different  periods  or  even  simultaneously 
in  the  same  child. 

There  is  often,  though  by  no  means  always,  a  characteristic  appearance 
of  the  patient,  but  it  is  quite  common  to  find  the  disease  under  discussion 
in  children  not  at  all  answering  to  either  description.  The  types  usually 
described  are  :  i.  Sanguine  type — the  child  is  tall,  slight,  graceful,  with 
small  fine  limbs,  clear  skin,  and  fine  silky  hair  ;  the  intelligence  is  bright. 
2.  Phlegmatic  type — the  child  is  short  and  thick-set,  with  coarse  skin  and 
limbs,  thick  features,  and  a  dull,  flabby  aspect.  3.  '  Pretty  strumous '  type 
— which  is  intermediate  between  the  two  former. 

Anatomically,  in  the  subjects  of  '  acute  miliary  tuberculosis '  we  find 
always,  or  nearly  so,  somewhere  in  the  body,  caseous  foci.  We  ought 
therefore  to  be  on  our  guard  against  the  onset  of  tuberculosis  in  vital  parts 
in  all  cases  where  such  caseous  foci  exist ;  for  instance,  the  common 
chronic  osteomyelitis  of  the  finger  may  be  the  only  discoverable  lesion 
in  an  apparently  robust  child,  yet  that  child  is  infected  with  tuberculosis 
and  may  at  any  time  develop  other  foci,  and  may  die  of  visceral  tubercle  ; 
hence  none  of  these  diseases  should  be  looked  upon  as  trivial.  It  must, 
however,  be  remembered  that  there  is  much  evidence  to  show  that  there 
is  some  antagonism  between  local  '  scrofulous '  lesions  and  general  vis- 
ceral tuberculosis,  or  rather  that  so  long  as  the  local  lesion  is  unrepaired 
the  internal  organs  escape,  while  recovery  from  the  local  disease  may  be 
followed  by  general  infection.  This  has  given  rise  to  the  view  that  the  local 
disease  acts  as  a  sort  of  safety  valve.  It  is  probable  that  the  truth  is  that 
so  long  as  the  local  lesion  remains  quiescent,  or,  as  it  were,  encapsuled,  no 
general  infection  takes  place,  but  if  from  any  cause  the  tuberculous  material 
gains  access  to  the  neighbouring  vessels  or  lymphatics,  a  rapid  dissemination 
of  the  tubercle  is  brought  about.  The  disease  often  lies  dormant  for  years 
or  for  a  long  lifetime,  and  the  patient  may  never  show  any  further  sign  of 
tuberculosis  ;  we  must  therefore  not  condemn  all  these  children  as  hope- 
lessly tuberculous.  Indeed  the  tendency  to  develop  tubercular  foci  often 
dies  out  after  a  time,  and  the  child  becomes  quite  sound.  Such  children 
should  be  taken  care  of  more  watchfully  than  others  need  be,  and  no  source 
of  irritation,  however  slight,  be  allowed  to  continue  ;  carious  teeth,  little 
patches  of  herpes  or  eczema,  slight  injuries,  and  so  on,  should  be  seen  to  at 
once,  lest  chronic  inflammation  should  ensue  and  a  tubercular  nidus  be  es- 
tablished. The  diet  in  all  such  cases  should  be  especially  nourishing,  and 
the  usual  remedies  of  cod  liver  oil  as  an  article  of  food  rather  than  a  medi- 
cine, iodine  in  some  form,  iron,  and,  above  all,  sea  air,  should  be  provided 


Scrofula  and  Tiiherailosis — Ttihercular  Adenitis        237 

where  practicable.  In  the  richer  class  of  patients  such  children  should  go 
to  school  by  the  seaside. 

Details  of  management  of  individual  lesions  will  be  found  in  the  various 
special  chapters. 

Tubercular  Adenitis. — As  already  pointed  out,  the  lymphatic  tissues 
are  those  most  commonly  and  most  extensively  attacked  by  tuberculosis,' 
and  lymphadenitis  is  commoner  than  lymphangitis,  since  any  solid  material 
taken  into  the  lymphatic  vessels  is  apt  to  be  arrested  in  the  adjacent  gland. 
The  thick  lips  and  nose  and  the  red  patches  and  eczematous  eruptions  of 
children  are,  as  pointed  out  by  Curnow,  '  reticular  lymphangitis.'  Under 
certain  circumstances  chilblains  are  probably  a  similar  condition.  Irritating 
matters  passing  up  the  lymph  stream  are  not,  however,  by  any  means  always 
arrested  at  the  nearest  glands,  partly  because  the  course  of  the  lymphatics 
varies  and  the  most  commonly  affected  glands  may  be  avoided  by  a  bye- 
route  and  those  further  on  attacked,  and  partly  because  the  material  pro- 
bably may  sometimes  pass  through  one  gland  and  involve  the  next,  or  after 
one  gland  has  become  inflamed  it  may  become  a  source  of  infection  to  the 
next  in  the  chain.  Hence  search  should  be  made  for  sources  of  irritation 
out  of  the  usual  path  if  none  are  found  in  the  common  positions.  If  one 
obvious  enlarged  gland  exists  the  presence  of  others  should  always  be  sus- 
pected. The  first  thing,  then,  when  a  child  is  brought  with  an  enlarged 
lymphatic  gland,  is  to  examine  the  whole  area  draining  to  that  gland  for 
some  source  of  irritation,  past  or  present  :  this  will  be  facilitated  by  the 
following  table,  where  the  principal  lymphatic  glands  and  their  collecting 
areas  are  given.'- 


Table  showing  the  Distribution  of  the  Lymphatic  Glands 
AND  their  Drainage  Areas. =* 

Head  and  Neck. 

*    Glands.  Drainage  Area. 

Suboccipital  .         .         .         .  I  ^j.^j^  posterior  half  of  head. 

Mastoid  .         .         .         .  ) 

Parotid .         .         .         .         .     drain    anterior    half  of  head,    orbits,    nose, 

upper  jaw,  upper  part  of  pharynx. 
Submaxillary         .         .         .     drain    the  lower   gums,  lower  part  of  face, 

and  front  of  mouth  and  tongue. 
Suprahyoid  or  submental       .     drain    anterior    part    of    tongue,    chin,    and 

lower  lip. 
Superficial  cervical        .         .     drain  external  ear,  side  of  head,  and  neck 

(lying  beneath  platysma)  and  face. 

Retro-p/iaryngeal  .         .         .     drain    nasal     fossse     and     pharynx     (upper 

part). 

1  Greig  Smith  has  remarked  upon  the  frequency  of  lesions  of  '  red  marrow '  as  an  illus- 
tration of  its  lymphatic  affinities. 

2  Curnow,  Lancet,    1879.     Sappey,  Anaf.-Phys.   Path,  des    Vaisseaiix  Lymphatiques, 
Paris,  1874. 

^  Mainly  from  Curnow  and  Treves. 


238 


Tuberculosis 


Glands. 
Deep  cervical : 

Upper  set  along  carotid 
sheath  : 


Lower  set  in  supra- 
clavicular fossae  : 


Supracondyloid  ^ 
Axillary 


Head  a?td  Neck. 

Drainage  Area. 

drain  mouth,  tonsils,  palate,  lower  part  of 
pharynx,  larynx,  posterior  part  of  tongue, 
nasal  fossae,  parotid  and  submaxillary 
glands,  interior  of  skull,  and  deep  parts 
of  head  and  neck. 

drain  upper  set  of  lymph  glands,  lower 
part  of  neck,  and  join  axillary  and 
mediastinal  glands. 

Upper  Extremity. 

drain  three  inner  fingers. 

drain  upper  extremity,  dorsal  and  scapular 

regions,  front   and    sides  of  trunk  and 

breast. 


Loiver  Extremity. 

Anterior  tibial  and  popliteal :     drain  the  deep  lymphatics  of  the  leg,  and 

receive  some  vessels  from  the  skin  of  the 
leg  and  foot,  chiefly  the  outer  side. 
Inguinal  : 

Femoral  set  (superficial")    .     drain  superficial  vessels  of  lower  limb  and 

partly    of  buttock    and    genitals,    also 
perinasum. 
Horizontal  set  (superficial)  :  drain    abdomen   below   umbilicus,    buttock 

and  genitals. 

The  deep  vessels  of  the  lower  limb 
go  to  the  deep  glands  along  the  femoral 


Iliac 

Lictnbar . 
Sacral    . 


Abdomen. 

drain  the  pelvic  viscera  and  the  deep  vessels 
of  the  genitals  partly. 

drain   all   the   lower   glands,    uterus,  testes, 
ovaries  kidneys. 

drain  the  rectum. 

Roughly,  the  umbilicus  is  the  water- 
shed draining  to  the  axilla  and  groin, 
but  the  vessels  cross  and  overlap  both 
vertically  and  horizontally. 


Perhaps  the  most  commonly  enlarged  gdands  are  those  of  the  neck  and 
submaxillary  regions,  parts  obviously  much  exposed  to  irritation  ;  thus  eczema 
of  the  scalp,  the  irritation  of  pediculi,  &c.  give  rise  to  enlargement  of  the 
occipital  and  upper  cervical  glands  ;  herpes  about  the  nose  to  irritation  of  the 


Occasionally  there  are  glands  in  the  bend  of  the  elbow. 


Tubercular  Adenitis  239 

parotid  or  submental  glands  ;  while  carious  teeth,  ulceration  of  the  gums,  and 
so  on,  affect  the  submaxillary  and  cervical  groups.  The  upper  set  of  cervical 
glands  are  found  enlarged  from  irritation  of  the  meatus  externus  in  cases  of 
otorrhoea  and  in  cases  of  tonsillitis.  As  already  mentioned,  a  lymph  gland 
overlies  the  tonsil,  and  is  usually  enlarged  in  affections  of  that  structure, 
which  is  not  perceptible  from  the  neck  under  ordinary  circumstances.  Treves 
points  out  that  those  glands  which  drain  areas  rich  in  lymphoid  tissue 
are  the  ones  most  commonly  enlarged  ;  hence  the  cervical,  bronchial,  and 
mesenteric  groups  are  those  most  often  affected. 

The  enlargement  of  lymphatic  glands  is  sometimes  acute  at  first,  and  they 
are  then  tender  and  painful  ;  in  other  instances  the  swelling  is  chronic  and 
painless  from  the  beginning.  The  glands  form  hard,  rounded,  or  oval  masses 
freely  movable  in  the  deeper  tissues  and  beneath  the  skin,  unless  there  has 
been  cellulitis  around  the  gland  (periglandular  inflammation).  In  chronic 
cases  the  o\erlying  skin  is  natural,  and  usually  se\eral  glands  can  be  felt  ; 
often  a  chain  of  them,  varying  in  size  from  a  pea  to  a  walnut,  can  be  traced.  A 
mere  transitory  irritation  may  start  inflammation  in  a  gland,  and  then, 
though  the  local  source  has  entirely  disappeared,  the  enlargement  may  persist 
and  other  glands  in  the  chain  be  affected,  as  already  described  ;  hence  we 
must  not  conclude  that  there  has  been  no  primary  source  of  irritation,  and 
that  the  glandular  affection  is  spontaneous  because  we  can  find  no  cause  for 
the  enlargement.  Cold,  or  some  trifling  injury,  a  sore  upon  the  skin  or 
mucous  surface,  soon  healed  and  forgotten,  or  perhaps  never  noticed,  is  suffi- 
cient to  set  up  chronic  tubercular  adenitis,  which  may  spread  and  last  for 
months  or  years.  Primary  adenitis  not  due  to  absorption  is  probably  very 
rare.  Treves  points  out  that  cervical  adenitis  may  be  caused  by  extension 
from  within  the  chest  or  other  distant  parts. 

x\fter  a  time,  unless  the  process  subsides,  the  glands  become  very  hard, 
and  by  their  size  and  number  give  rise  to  great  disfigurement  and  occasion- 
ally to  more  serious  trouble.  Goode,  of  Cincinnati,  has  recorded  a  case  of 
death  in  a  baby  five  months  old  from  pressure  of  a  caseous  gland  upon  the 
carotid  sheath.  These  swellings  are  seldom  painful  ;  after  a  time  one  or  more 
patches  of  softening  may  appear,  and  as  the  process  goes  on  the  skin  becomes 
red  or  livid,  and  finally  thinned  and  perforated  ;  thin  water)',  sero-purulent 
fluid  with  flakes  of  lymph  and  cheesy  matter  then  escape,  more  rarely 
fairly  healthy-looking  pus  ;  occasionally  the  discharge  is  clear  glairy  fluid, 
like  the  contents  of  some  mucous  cysts,  but  in  such  cases  there  is  almost 
always  some  more  purulent  matter  at  the  bottom  of  the  cavity,  which  can 
be  squeezed  out.  The  discharge  may  go  on  indefinitely,  and  an  ulcer  is 
formed  which  has  little  tendency  to  heal,  and  is  bounded  by  thin,  livid, 
undermined,  unhealthy  edges.  If  healing  does  take  place  the  scar  is 
puckered  and  unsightly,  often  with  bridges  or  tags  of  thin  insensitive  skin 
hanging  from  it,  and  little  black  spots  due  to  accumulation  of  dirt  and 
secretion  in  the  hollows  of  the  scar.  Such  is  the  condition  seen  in  an  old 
'  scrofulous  neck.' 

If  such  a  gland  as  that  above  mentioned  is  examined  in  the  early  stages 
of  the  process,  it  will  be  found  firmer  and  paler  than  in  health,  but  not  other- 
wise obviously  altered  ;  a  little  later  patches  of  yellow  cheesy  material  of 
various  sizes  will  be  found  scattered  through  the  gland,  sometimes  in  one  or 


240  Tuberculosis 

two  large  foci,  at  other  times  in  numerous  small  ones  ;  the  capsule  of  the 
gland  is  thickened.  Later  still,  these  caseous  foci  break  down,  the  greater 
part  of  the  gland  tissue  is  destroyed,  and  the  gland  itself  becomes  converted 
into  a  bag  of  cheesy  or  flaky  pus  and  detritus,  with  walls  composed  of  the 
capsule  and  more  or  less  of  the  gland  tissue  remaining  unsoftened.  It 
happens,  however,  sometimes  that,  instead  of  the  gland  breaking  down  and 
softening  in  the  centre,  suppuration  takes  place  in  the  cellular  tissue  round 
it — periglandular  abscess  ;  this  burrows  round  the  gland  and  isolates  it,  so 
that  there  is  a  solid  mass  of  gland  tissue  lying  in  an  abscess  cavity,  and  per- 
haps attached  to  the  surrounding  tissues  only  by  the  structures  passing  to  its 
hilus.  In  this  last  case,  when  the  skin  gives  way,  instead  of  a  deep  ulcer 
there  is  seen  a  round  pinkish  or  yellowish-white  mass  projecting  from  the 
middle  of  a  circular  sore,  the  edges  of  which  are  loose,  undermined,  thin,  and 
livid  ;  there  is  often  but  little  discharge,  and  no  tendency  to  heal,  or,  indeed, 
to  alter  much  one  way  or  the  other.  Where  many  glands  are  enlarged,  all 
stages,  from  the  first  primary  enlargement  to  the  last-named  condition,  may 
be  seen  at  once,  and  sometimes  the  whole  neck  from  ear  to  ear  is  marked  by 
ulcers,  scars,  and  enlarged  glands  in  various  stages.  In  such  cases  it  will 
usually  be  found  that  many  teeth  in  one  or  both  jaws  are  carious,  and  acting 
as  sources  of  irritation. 

It  must,  of  course,  be  remembered  that  all  such  glands  do  not  go  on  to 
suppuration,  and  perhaps  in  children  there  is  more  chance  of  resolution 
than  in  adults  ;  however,  the  majority  do  suppurate  if  they  I'emain  enlarged 
for  more  than  a  short  time. 

Coexisting  with  the  glandular  abscesses  and  sores  will  often  be  found 
superficial  ulcers,  round  or  irregular  in  form,  often  scabbed  over,  and  only 
discharging  at  times.  The  edges  of  the  sores  are  usually  unhealthy  and 
undermined,  and  their  bases  glazed  or  covered  with  coarse,  unhealthy  granu- 
lations and  caseous  detritus  ;  some  of  the  ulcers  are  no  doubt  caused  by  the 
discharge  of  broken-down  glands  ;  in  these  a  small  aperture  will  be  found 
leading  down  to  the  underlying  gland  ;  others  are  probably  due  to  abscesses 
beginning  in  lymphatic  vessels,  due  to  tubercular  lymphatic  emboli,  or  rather 
thrombi — tubercular  lymphangitis,  'strumous  nodes  ; '  others  again  probably 
to  local  cutaneous  tuberculosis. 

Diagnosis. — -Tuberculous  adenitis  and  ulcers  may  be  mistaken  for 
syphilitic  ulceration,  which  gives  rise  to  very  similar  appearances,  except 
that  ulceration  predominates  over  the  glandular  enlargement.  It  must  be 
remembered  that  congenital  syphilis  and  tuberculosis  may  coexist.  The 
presence  of  other  evidences  of  syphilis  will  nearly  always  clear  up  a  doubt. 

Simple  acute  adenitis  is  recognised  by  its  short  history  and  by  the  pain 
and  great  tenderness  of  the  part,  as  well  as  by  the  presence  of  an  acute 
source  of  irritation,  such  as  an  alveolar  abscess  or  acute  tonsillitis,  and  by 
the  fact  that  usually  only  one  gland  is  enlarged,  though  several  may  be 
tender. 

Simple  non-tubercular  chronic  adenitis  may  occur  as  the  result  of  acute 
inflammation,  but  this  usually  rapidly  subsides  under  treatment  and  affects 
but  one  gland  ;  if  the  affection  is  obstinate,  suspicion  of  its  tuberculous 
nature  should  be  aroused. 

Lupous  ulcers  are  the  only  other  condition  likely  to  be  mistaken,  and  as 


Treatment  of  Tubercular  Adenitis 


241 


these  arc  also  tuberculous,  the  mistake  is  of  little  importance.  The  presence 
of  well-defined  lupous  tubercles  is  the  distinguishing  feature. 

Tuljerculous  abscess  of  the  skin,  '  scrofuloderma,'  '  scrofulous  gunmia,' 
and  '  strumous  node,'  are  the  names  applied  to  small  tuberculous  foci  pro- 
bably in  the  lymphatics  which,  at  first  hard  and  solid,  usually  break  down, 
though  sometimes  they  are  absorbed.  These  little  swellings  are  often 
found  in  the  thickness  of  the  skin  itself  about  the  limbs,  face,  or  trunk. 
Occasionally  the  mischief  spreads,  and  a  large  cold  abscess  or  tuberculous 
ulcer  may  result. 

Chronic  tonsillar  hypertrophy  is  considered  by  Treves  to  be  'almost 
pathognomonic  of  scrofula  ; '  though  very  common  in  tubercular  children,  we 
think  it  is  otten  met  with  in  those  who  show  no  other  signs  of  tuberculosis  ; 
it  mav  occur  during  the  first  few  months  of  life.     Infantile  leucorrhoea  and 


Fig.  46a.  —Tubercular  Ulceration  of  the  Skin  of  the  Foot,  showing  imperfectly  formed  scar-tissue 
overlying  the  tuberculous  granulations.     A  form  of  so-called  Lupus  hypertrophlcus. 


certain  vulvar  ulcers  have  been  supposed  to  be  tuberculous  ;  no  doubt  many 
cases  of  aural  suppuration  are  so. 

Treatment. — The  treatment  of  tuberculous  adenitis  consists  at  first  in 
carefully  removing  all  sources  of  irritation  ;  carious  teeth,  enlarged  tonsils, 
patches  of  eczema,  nasal  catarrh,  otorrhoea,  chafed  heels,  and  so  on,  should 
all  receive  attention  according  to  the  seat  of  the  enlarged  glands  and 
the  source  of  the  trouble.  Next,  the  general  measures  of  diet  and  health 
already  mentioned  must  be  carried  out.  As  to  the  local  treatment  of  the 
glands  themselves,  this  must  be  managed  according  to  the  stages  of  the 
disease,  (i)  In  the  early  stage,  before  caseous  foci  have  appeared,  after 
removal  of  the  source  of  irritation,  the  glands  should  be  left  quite  alone,  in  the 
hope  of  their  subsiding.  If  no  improvement  takes  place  in  a  fortnight,  the 
glands  should  have  a  piece  of  unguentum  hydrargyri  oleati,  of  the  size  of  a 
small  pea,  gently  rubbed  over  them  night  and  morning.  Painting  with 
tincture  of  iodine  we  do  not  approve  of  ;  it  is  far  more  likely  to  increase  the 

R 


242  Tuberculosis 

irritation  of  the  glands  than  to  lessen  it.  Should  the  enlargement  not  yield 
to  these  means,  and  should  the  stage  of  caseation,  known  by  a  duration  of 
two  or  three  months  with  considerable  enlargement  and  much  hardening  of 
the  glands,  be  reached,  the  best  treatment  is  to  cut  down  upon  and  shell  out 
the  glands  entire — a  very  easy  operation  at  this  stage  where  only  one  or  two 
glands  are  involved,  a  much  more  difficult  and  sometimes  impossible  one 
where  many  glands  in  a  chain  are  enlarged  and  there  is  periglandular  in- 
flammation. In  favourable  cases  an  incision  through  the  skin  and  fascia, 
and  the]  1  through  the  sheath  of  the  gland,  followed  by  pressure  at  each  side 
with  the  fingers,  will  render  enucleation  of  the  mass  quite  easy.  All  the 
glands  felt  to  be  enlarged  should  be  removed,  all  bleeding  stopped,  and  the 
edges  carefully  brought  together,  no  drainage  being  used  if  the  wound  is 
clean.  The  resulting  scar  is  slight,  and  much  less  unsightly  than  that  left 
in  cases  where  suppuration  has  gone  on.  The  plan  of  puncture  with  the 
thermo-cautery  we  have  not  found  satisfactory  ;  it  is  apt  to  leave  intractable 
sinuses. 

In  the  next  stage,  when  the  gland  has  softened  down,  if  there  has  been 
no  periglandular  mischief,  it  may  be  still  possible  to  dissect  the  mass  out, 
and,  if  so,  this  is  the  quickest  and  best  method  ;  it  is,  however,  impracticable 
if  the  glands  have  become  matted  to  the  surrounding  tissues  :  in  such  cases 
the  abscess  should  be  opened  by  an  incision  about  half  an  inch  in  length  ;  a 
long  incision  is  not  necessary,  but  it  must  be  sufficient  for  free  manipula- 
tion and  drainage.  After  opening  the  abscess  a  Volkmann's  spoon  is  passed 
in,  and  all  the  gland  tissue  carefully  and  thoroughly  scraped  away  :  if  any  is 
left  the  wound  will  not  heal,  but  the  part  remaining  will  caseate,  break  down, 
and  keep  open  a  sinus  ;  hence,  if  all  the  gland  cannot  be  scraped  away,  the 
most  satisfactory  plan  is  to  enlarge  the  incision  and  dissect  out  the  remaining 
parts.  Injection  of  chronic  glandular  abscesses  with  a  solution  of  iodoform 
in  ether  is  worth  a  trial  where  operation  is  not  allowed  ;  we  have  seen 
them  completely  disappear  under  this  treatment.  Where,  as  often  happens, 
two  or  more  glands  near,  but  not  fused  with,  one  another  have  broken  down, 
the  further  ones  may  often  be  reached,  as  pointed  out  by  Mr.  Teale,  by 
thrusting  the  spoon  through  the  adjacent  walls  and  thus  emptying  all  the 
cavities  through  one  opening.  The  wound  should  be  well  dusted  with  iodo- 
form and  drainage  provided  for.  When  the  abscess  has  already  burst  and 
left  a  sinus,  the  same  treatment  should  be  adopted.  Where  ulcers  have 
formed  with  undermined  edges  these  should  be  scraped  or  clipped  away 
flush  with  the  healthy  skin  :  a  large  wound  may  thus  be  sometimes  left 
where  there  was  but  a  small  opening  before,  but  the  ultimate  result  will  be  a 
much  less  unsightly  scar,  as  well  as  more  rapid  healing,  if  this  devitalised 
skin  is  removed  ;  all  the  unsightly  tags  and  bridges  will  thus  be  avoided. 
Where  there  is  a  protruding  isolated  gland  in  the  middle  of  a  sore,  if  it  is 
soft  it  may  be  scraped  away.  We  cannot  too  strongly  urge  that  on  every 
ground  it  is  far  wiser  to  remove  glands  by  clean  excision  as  soon  as  they  have 
become  chronically  enlarged,  and  before  there  is  any  breaking  down  or  in- 
flammation round  the  gland. 

Mr.  Teale  has  pointed  out  that  where  one  superficial  gland  is  enlarged 
and  suppurating  there  is  usually  another,  lying  beneath  the  deeper  fascia,  and 
that,  unless  this  is  cleared  out,  the  source  of  discharge  is  not  removed  and 


Treatment  of  Tubercular  Adenitis  243 

the  sinus  will  not  heal.  It  is  necessary  to  look  carefully  sometimes  to  find 
the  channel  leading  to  the  deep  gland,  but  it  is  there  and  must  be  followed  by 
the  spoon,  and  the  second  mass  removed.  Mr.  Teale  uses  a  special  dilator 
to  stretch  the  sinus,  but  a  dressing  or  sinus  forceps  will  usually  be  found  to 
answer  all  purposes. 

Iodoform  is  the  best  dressing  to  apply  to  these  sores  at  first,  and  later  on 
they  do  very  well  with  iodide  of  lead  ointment. 

Where  several  sinuses  are  left  in  the  neck  it  is  a  good  plan  to  use,  as 
advised  by  Treves,  a  gutta-percha  or  leather  stock  to  keep  the  parts  at  rest 
(the  sawdust  collar  will  be  found  useful  for  this  purpose),  and  in  other  parts 
of  the  body  efficient  pressure  by  pads  and  bandages  or  by  a  truss  is  often 
useful. 

Where  depressed  scars  remain  after  gland  diseases  Adams's  or  Reeves's 
operations  may  be  employed.  The  former  loosens  the  skin  by  subcutaneous 
division  of  the  scar,  and  by  daily  manipulation  keeps  it  from  becoming 
reattached  till  the  hollow  is  filled  up.  Reeves  props  up  the  depressed  skin 
upon  a  wire  passed  beneath  it,  which  may  be  left  in  permanently,  or  removed 
if  it  sets  up  irritation.  We  have  had  a  good  result  from  the  latter  method. 
A  far  better  plan,  however,  in  most  cases  is  to  cleanly  excise  the  whole 
scar,  and  bring  the  edges  of  sound  skin  accurately  together  by  means  of 
sutures  ;  thus  a  linear  cicatrix  takes  the  place  of  the  irregular  puckered  or 
depressed  scar. 

Where  the  popliteal  or  inguinal  glands  are  involved  the  limb  should  be 
kept  extended  and  fixed  to  a  splint.  Suppurating  popliteal  glands  are  apt 
to  give  rise  to  serious  trouble  ;  the  matter  tends  to  burrow  far  up  the  limb. 
In  one  case  we  had  to  amputate  the  thigh  where  an  abscess,  beginning 
in  the  popliteal  lymphatics  as  the  result  of  an  irritated  chilblain,  eroded 
the  popliteal  artery,  opened  into  the  knee  joint,  and  burrowed  up  to  the 
pelvis. 

Acute  adenitis,  if  seen  before  suppuration  has  occurred,  will  usuall)'  sub- 
side if  the  source  of  irritation  is  removed  and  the  part  well  fomented  after 
smearing  it  with  extract  of  belladonna.  If  pus  forms  it  should  be  let  out  as 
soon  as  possible. 

General  Surg^ical  Tuberculosis 

A  condition  perhaps  best  described  as  '  general  surgical  tuberculosis  ' 
is  common,  the  term  being  applied  to  those  cases  where  there  are  tubercu- 
lous foci  scattered  far  and  wide  over  the  body  in  various  tissues.  Thus 
children  are  seen  with  ulcers  of  the  hands,  abscesses  or  still  unsoftened 
nodes  along  the  course  of  the  lymphatics  of  the  fore-arm,  and  a  supra- 
condylar gland  enlarged  :  perhaps  a  patch  of  ulceration  on  the  cheek 
and  submaxillary  adenitis,  phlyctenular  ophthalmia,  tubercular  osteo- 
myelitis of  one  tibia,  with  disease  of  the  tarsus  on  the  opposite  side,  and 
so  on.  Such  a  combination  is  by  no  means  a  rarity  :  not  very  long  ago  we 
had  in  the  hospital  a  boy  with  disease  of  one  hip,  one  elbow,  one  ankle, 
and  sacro-iliac  disease  ;  in  another  the  shoulder,  ankle,  and  wrist  were 
all  excised  for  tuberculous  disease.  Such  cases,  if  they  are  neglected, 
gradually  lose    strength    and  sink,  but    good  food  and    sea  air,    combined 

R  2 


244 


Tuberculosis 


with  removal  of  the  disease  as  soon  as  it  is  evident  that  spontaneous  repair 
is  impossible,  will  often  work  wonders. 

Operation  should  be  deferred  till  it  is  seen  what  nature  can  do  ;  but  if 
with  the  improvement  in  the  child's  health  no  progress  is  made  locally,  or  if 
there  is  pain  or  much  discharge,  the  affected  tissues — bones,  joints,  &c. — 
should  be  removed.  We  have  often  been  surprised  at  the  rapid  and  com- 
plete repair  effected  in  such  children,  and  even  in  the  cases  looking  most 
desperate  locally,  resections  or  scrapings  will  sometimes  succeed  and  am- 
putations prove  unnecessary.^  But  in  all  these  children  relapses  will  occur 
if  the  health  is  again  allowed  to  fail  from  bad  food  and  hygiene. 

As  regards  details  of  local  treatment  in  such  cases,  we  find  iodoform 
mixed  with  an  equal  quantity  of  boric  acid  and  dusted  on,  or  iodoform 
ointment,  the  best  application.  Where  operation  is  called  for,  all  dead  and 
carious  bone  should  be  excised  or  scraped  and  gouged  away,  all  soft  caseous 
and  pulpy  granulation  tissue  removed,  and  undermined  livid  edges  of  skin 
clipped  off".  The  incisions  may  sometimes  be  closed  with  sutures  and 
primary  union  obtained  ;  where  possible  this  should  be  attempted.  If, 
howevei-,  the  destruction  of  the  skin  renders  union  impossible,  the  wounds 
should  be  left  freely  open  ;  they  often  heal  with  great  rapidity  and  leave  but 
little  deformity.  Amputation  is  sometimes  required  for  tarsal  and  knee  joint 
disease,  but  in  the  upper  extremity  we  have  7tever  seen  a  case  that  required 
it,  except  in  the  fingers,  though  some  have  at  first  appeared  hopeless  enough. 
Caries  of  the  spine  in  such  children  is  the  most  serious  condition,  from  its 
inaccessible  position  ;  but  even  this  is  not  hopeless.  It  is  not  so  common  as 
might  be  expected  to  find  visceral  tubercle  in  these  patients,  and  this  is 
probably  one  of  the  reasons  why  they  have  been  called  scrofulous  and  not 
classed  as  tubercular.  The  term  '  surgical  tuberculosis '  has  been  used  to 
imply  that  operative  treatment  can  do  much  for  them,  and  that  the  lesions 
are  external.     The  following  case  illustrates  this. 

Surgical  Tuberculosis. — Ed  ward  C,  aged  9  years  6  months.  Admitted  November  7, 
1885.  No  tubercular  history.  Always  healthy  till  two  years  ago,  when  an  abscess 
appeared  at  .the  back  of  the  leg,  and  others  subsequently  elsewhere  ;  they  have  continued 
to  discharge  since.  Four  months  ago  he  fell  upon  the  elbow,  and  an  abscess  formed, 
which  was  opened,  and  has  been  discharging  since ;  joint  stiff.  On  admission,  a  sinus 
over  the  outer  end  of  the  left  clavicle,  leading  to  bare  bone.  Abscesses  and  enlarged  glands 
in  the  neck  ;  a  sinus  on  the  left  buttock  and  another  over  the  inner  condyle  of  the  left 
humerus.  26th,  several  small  loose  sequestra  removed  from  the  cavity  in  the  clavicle,  close 
to  and  involving  the  acromio-clavicular  joint ;  abscess  in  neck  scraped  out  and  a  deep 
gland  beneath  the  fascia  scooped  away  ;  some  caseous  bone  scraped  from  inner  condyle 
of  humerus.  27th,  much  pain  in  elbow,  which  subsided  partially  by  the  29th  ;  he  did  fairly 
well,  and  was  sent  out  on  December  11  with  all  the  ulcers  &c.  doing  well,  except  the 
elbow,  which  remained  swollen  and  tender.     Such  cases  are  very  frequently  met  with. 

xron-tubercular  Abscess 

Chronic  Abscess. — Chronic  abscesses,  whether  tubercular  or  not,  may 
now  be  dealt  with  much  more  speedily  and  satisfactorily  than  in  former 
times.  In  all  cases,  of  course,  the  source  of  irritation  should  be  looked  for 
and  if  possible  removed  ;  unless  this  is  done  success  cannot  be  reasonably 
expected. 

1  See,  however,  chapter  on  Bone  and  Joint  Diseases. 


Non-Tubercular  Abscess  245 

In  some  instances,  if  the  contents  of  the  abscess  are  drawn  off  through 
an  aspirator  and  an  emulsion  of  iodoform  in  glycerine  injected  (from  ;^j. — J^s. 
being  a  usual  quantity  to  use),  the  abscess  will  slowly  subside.  This 
method  is  not,  however,  likely  to  succeed  where  any  irritating  or  much 
caseous  material  is  present.  In  such  cases  the  abscess  should  be  freely 
opened  and  its  contents  and  whole  lining  most  carefully  scraped  and  rubbed 
away  ;  this  part  of  the  proceeding  must  be  done  thoroughly  or  the  operation 
will  fail. 

The  abscess  cavity  should  then  be  well  washed  out  with  perchloride 
of  mercury  lotion  of  strength  i  to  3,000,  and,  after  being  thoroughly  dried 
out,  either  a  mixture  of  iodoform  and  boric  acid  in  equal  parts  should  be 
dusted  in,  or  some  of  the  iodoform  emulsion  injected.  The  wound  is  then  to 
be  carefully  and  completely  sewed  up,  all  excess  of  fluid  being  squeezed  out 
just  before  the  dressings  are  applied.  The  dressings  should  consist  of  wood- 
wool wadding  or  some  similar  substance  packed  carefully  on  over  a  layer  of 
wet  gauze.  The  dressing  should  be  so  applied  that  the  walls  of  the  cavity 
are  accurately  kept  in  contact  and  firm  pressure  made.  In  successful  cases 
the  wound  need  not  be  disturbed  for  ten  days  or  a  fortnight,  when  it  will  be 
found  soundly  healed.  If,  as  sometimes  happens,  the  wound  heals  but  the 
abscess  refills,  either  the  source  of  irritation  at  a  distance  has  not  been 
removed,  or  the  cleaning  out  of  the  cavity  has  not  been  complete  ;  the 
operation  should  be  repeated,  and  will  probably  be  successful.  In  cleaning 
out  the  cavity  it  is  useful  to  twist  an  artificial  sponge  tightly  into  all  parts 
of  the  cavity  and  screw  it  round  so  as  to  entangle  and  wipe  out  all  caseous 
material. 

Deep  Cervical  Cellulitis — Ang'ina  Iiudovici — is  a  very  serious  affection  ; 
the  mischief  apparently  begins  as  a  periglandular  inflammation,  goes  on  to 
sloughing,  and  may  perforate  the  cheek.  There  is  at  first  a  brawny  infiltration 
of  the  submaxillary  region  ;  the  skin  in  milder  cases  is  pale  and  marked  by 
turgid  veins  ;  in  the  more  severe  and  acute  cases,  however,  a  deep  brownish- 
red  discoloration  appears.  The  whole  neck  may  be  involved,  and  there  is 
great  swelling,  with  marked  prostration,  and  sometimes  dyspnoea  or  dysphagia 
from  mechanical  pressure.  The  disease  is  met  with  usually  in  children  under 
three  years  of  age,  often  in  infants,  and  occurs  under  similar  conditions  to 
cancrum  oris.  Early  and  free  incision  is  urgently  required  ;  usually  much 
foul  brown  serum  or  sero-pus  escapes.  Free  stimulation  and  abundant 
nourishment  are  required,  with  removal  from  insanitary  surroundings. 
The  mortality  of  these  cases,  which  much  resemble  those  of  scarlatinal 
cellulitis,  is  considerable. 

Case. — Female,  age  i  year  9  months  ;  neck  swollen  a  fortnight  ago ;  on  admission, 
right  side  of  neck  tense,  hard,  brownish-red  ;  swelling  reaches  to  clavicle  ;  swelling  incised, 
serum  only  escaped  ;  much  fever  before  incision  ;  skin  sloughed  freely,  and  pneumonia 
set  in,  child  dying  on  seventh  day. 

Post-mortem. — Abscesses  in  lungs  and  sanguineous  pleuritic  effusion. 


246  ■        The  Specific  Fevers 


CHAPTER   XIV 

THE    SPECIFIC    FEVERS 

reverishness. — Children  more  often  than  aduks  are  apt  to  suffer  from 
attacks  of  feverishness,  the  temperature  rising  suddenly  without  any  obvious 
cause,  remaining  raised  for  a  day  or  two,  much  to  the  alarm  of  the  friends 
and  the  medical  attendant,  and  returning  to  normal  without  any  clue  having 
been  obtained  as  to  the  cause.  Perhaps  the  feverishness  is  less  acute,  but 
continuous  for  some  weeks,  rising  in  the  evening  and  falhng  in  the  morning, 
without  any  diagnosis  being  made.  It  is  hardly  needful  to  insist  that  in  any 
given  case  no  effort  should  be  spared  to  find  out  the  cause  of  the  fever,  the 
chest  being  stripped  and  carefully  examined  by  auscultation  and  percussion, 
while  the  skin  and  fauces  should  be  minutely  scrutinised  in  a  good  light. 
Inquiries  should  be  made  as  to  what  the  child  has  taken  in  the  way  of  food 
prior  to  the  attack.  If  the  attack  is  sudden,  the  temperature  rising  to 
103°  or  104°  or  more,  epidemic  influenza,  acute  pneumonia,  scarlet  fever, 
or  acute  dyspepsia  from  the  ingestion  of  unsuitable  food  will  doubtless  be 
suggested. 

In  children  under  three  years  of  age,  a  high  temperature  with  convulsions 
is  often  due  to  acute  pneumonia,  and  a  careful  examination  of  the  lungs, 
especially  at  the  apices,  should  be  made  ;  in  older  children  there  may  be  no 
convulsions,  but  usually,  if  the  physical  signs  are  not  distinctive,  there  is 
some  stitch  in  the  side  felt  on  coughing,  with  more  or  less  dyspnoea.  In 
scarlet  fever  there  is  usually  vomiting  and  often  diarrhoea,  and  the  appear- 
ances in  the  throat  and  skin  soon  become  distinctive.  During  the  first  twelve 
or  twenty-four  hours  it  may  be  difficult  to  distinguish  between  scarlet  fever 
and  an  acute  gastro-intestinal  infection,  as  sometimes  the  latter  will  produce 
severe  symptoms  of  vomiting,  diarrhoea,  and  fever.  Or  there  may  be  no 
diarrhoea  or  sickness  and  only  feverishness.  The  diagnosis  in  epidemic 
influenza  has  often  to  be  made  from  the  fact  that  it  is  prevalent  in  the  house 
or  neighbourhood  rather  than  from  the  symptoms,  which  are  so  frequently 
indefinite  ;  a  temperature  of  104°  or  105°  with  convulsions  is  not  uncommon. 
In  many  cases  it  is  wise  to  wait  before  giving  a  definite  opinion,  In  infants 
and  young  children  the  cause  of  an  unexplained  high  fever  may  pi-ove  to  be 
an  acute  otitis  which  has  been  overlooked  till  pus  has  made  its  appearance 
at  the  external  meatus  ;  such  cases  are  very  apt  at  first  to  be  mistaken  for 
meningitis  (see  fig.  47). 

In  some  feverish  attacks  we  have  noticed  an  enlargement  of  the  cervical 
glands,  either  the  deep  cervical  at  the  angle  of  the  jaw,  or  the  glands  under  the 
upper  part  and  posterior  edge  of  the  sterno-mastoid,  without  any  appearances 


Feverishness 


247 


of  irritation  in  the  tonsil  or  pharynx  ;  possibly  there  may  be  such  a  disease 
as  an  acute  idiopathic  adenitis,  or  some  poison  may  perhaps  be  absorbed 
from  the  pharynx  and  enter  the  glands  without  setting  up  any  local  lesion  at 
the  point  of  absorption. 

Such  cases  have  been  described  by  E.  Pfeififer,  Heubner,  and  Rauchfuss., 
under  the  name  of  grland  fever.  The  attack,  according  to  Pfeiffer,  is  sudden 
and  the  fever  moderately  high  ;  there  is  complaint  of  tenderness  in  the  neck, 
and  some  of  the  cervical  glands,  usually  those  at  |the  posterior  border  of  the 
sterno-mastoid,  or  the  occipital  glands,  are  swollen  and  tender.  In  a  few 
days  the  temperature  falls  and  the  glands  become  normal.  In  a  few  instances 
the  attack  has  been  more  severe  and  has  lasted  longer.     In  these  cases  no 


Fig.  47. — Temperature  Chart  showing  high  temperature  due  to  an  acute  otitis  in  an 
infant  of  seven  months. 

abnormal  appearances  have  been  detected  in  the  tonsils  or  nasal  mucous 
membrane.  The  glands  never  suppurate.  Pfeififer  has  noted  several  of 
these  cases  in  one  house  at  the  same  time,  the  disease  being  infectious  or 
epidemic. 

We  are,  however,  rather  inclined  to  think  that  while  '  gland  fever '  does 
undoubtedly  take  place,  it  is  rarely  idiopathic,  but  the  result  of  absorption  of 
toxic  materials  from  a  mucous  membrane.  'Gland  fever'  often  occurs  m 
scarlet  fever  and  other  various  forms  of  tonsillitis,  the  throat  may  be 
apparently  well  or  hardly  abnormal,  yet  the  cervical  glands  are  swollen  and 
tender,  and  the  patient  feverish. 

Acute  cerebral  cong-estion  or  '  sunstroke  '  may  be  accompanied  by  high 


248 


The  Specific  Fevers 


fever,  quickly  followed  by  death,  though  fortunately  this  is  not  always  the 
case.  In  many  cases  with  a  high  temperature  and  cerebral  symptoms,  such 
as  coma,  delirium,  or  torpor,  it  is  often  difficult  to  say  whether  there  is  some 
cerebral  disease,  or  whether  the  high  temperature  and  poisoned  blood  are 
not  causing  the  cerebral  symptoms,  the  brain  itself  being  normal.  When 
the  temperature  rises  more  slowly,  taking  several  days  to  reach  its  greatest 
elevation,  as  is  the  case  in  measles,  typhus,  typhoid,  and  smallpox,  a  diagnosis 
cannot  be  made  for  a  few  days,  till  characteristic  symptoms  appear.  The 
hard  cough,  suffused  eyes,  and  rash  of  measles,  the  headache,  dehrium,  and 
coma  of  typhus,  the  backache,  and  papules  of  smallpox,  settle  the  diagnosis. 


DATE   Hfi'      19       20         21        ea       23    1   24       2 5_ I   26 J    S 7„UW-19=^4aJ^^ 


MBaMEBmmEp||BEii|EBEE|EEEEEEEEEE 


Fig.  48.  — Temperature  Chart  of  a  case  of  Erythema  Nodosum.  The  girl  was  in  hospital  convalescent 
from  Acute  Pneumonia.  The  cause  of  the  fever  was  unknown  till  a  number  of  typical  nodes  made 
their  appearance. 

This  is  sometimes  the  case  in  erythema  nodosum  ;  there  are  some  few  days 
of  fever  with  no  definite  symptoms,  and  then  the  characteristic  red  flattened 
nodes  make  their  appearance  (see  fig.  48). 

The  diagnosis  as  to  the  cause  of  fever  is  often  very  difficult  when  the 
fever  assumes  the  intermittent  or  remittent  type,  going  on  for  some  days  or 
weeks  without  any  characteristic  symptoms  developing.  Such  cases  were 
formerly  designated  'low'  or  'continued  fever,'  and  while  it  is  not  wise  to 
use  such  indefinite  terms,  we  must  be  prepared  to  find  cases  of  intermittent 
fever  in  children  in  which  it  may  be  quite  impossible  to  make  a  diagnosis. 
A  sub-acute  or  chronic  gastro-intestinal  catarrh,  creeping  pneumonia,  a  low 
form  of  enteric  fever,  a  tubercular  peritonitis  or  suppuration  may  be  present. 


Scarlet  Fever  249 

There  may  be,  as  Dr.  Foxwell  suggests  in  these  cases,  a  condition  of 
general  catarrh,  including  both  alimentary  and  respiratory  tracts.  In  all 
such  cases  a  most  careful  examination  should  be  made  of  the  chest,  abdomen, 
and  retina  for  disseminated  tuberculosis,  in  the  hope  of  detecting  something 
which  will  throw  light  on  the  attack.  We  must  not  forget  that  some  of  these 
cases  of  protracted  remittent  fever  are  in  reality  cases  of  miliary  or  local 
tuberculosis  in  which  healing  eventually  takes  place.  We  feel  sure  we  have 
seen  such  cases. 

Scarlet  Fever 

Scarlet  fever  is  a  specific  fever  of  a  highly  infectious  and  dangerous 
nature  characterised  by  tonsillitis,  fever,  and  a  diffuse  rash  ;  it  occurs  in 
epidemics,  but  is  always  more  or  less  endemic  in  large  populations.  It  is 
easy  to  understand  the  occurrence  of  epidemics  in  a  small  population  where 
the  fever  exhausts  the  soil,  as  it  were,  by  attacking  all  those  susceptible  to 
its  influence,  and  then  disappears  for  a  while  to  prevail  at  a  later  period, 
when  the  infection  is  re-introduced  and  the  population  contains  again  a 
number  of  the  unprotected.  It  is  more  difficult,  however,  to  understand  the 
cause  of  epidemics  in  large  cities  where  the  infection  is  ilways  present, 
unless  we  assume  the  existence  of  some  unknown  influence  which  favours 
the  spread  of  the  disease  at  one  time  more  than  another  by  rendering  those 
who  are  unprotected  by  a  former  attack  more  than  usually  susceptible  to  the 
infection.  Thus  epidemics  of  scarlet  fever  are  more  common  and  wide 
spread  in  the  autumn  than  at  any  other  period,  and  it  would  appear  that  at 
this  season  either  the  poison  is  apt  to  be  more  intense,  or  individual 
susceptibility  greater.  Individual  susceptibility  varies  greatly  with  age 
infants  under  six  months  of  age  are  rarely  attacked,  during  the  second  year 
the  susceptibility  is  greater,  while  children  during  the  fourth  to  the  seventh 
years  are  most  often  attacked.  The  susceptibiHty  then  appears  to  diminish 
as  age  increases,  though,  as  already  remarked,  varying  strangely  from  time 
to  time.  Thus  it  may  happen  that  a  medical  man  or  nurse  may  come  in 
contact  with  scarlet  fever  cases  for  weeks  or  perhaps  months  without  con- 
tracting the  disease  and  yet  finally  take  it.  In  one  case  which  came  under 
our  notice  a  probationer  nurse  was  engaged  in  nursing  in  a  scarlet  fever 
ward  for  six  months  without  being  attacked  ;  many  months  after,  while 
nursing  in  a  surgical  ward  at  another  hospital,  she  contracted  a  smart  attack 
of  scarlet  fever  from  a  sporadic  case  arising  in  the  ward.  In  another  case 
a  child  had  a  severe  attack  of  scarlet  fever  twenty-nine  days  after  admission 
to  the  scarlet  fever  ward.  In  this  case  it  was  supposed  to  have  had  an 
attack  of  scarlet  fever  for  which  it  was  sent  in  ;  but  second  attacks  of  scarlet 
fever  are  rare  ;  they  do,  however,  undoubtedly  occur,  as  in  the  following  case: 

Scarlet  Fever ;  second  attack. — Thomas  R.,  aged  6  years.  Vomited  June  26,  rash 
noted  same  day ;  admitted  to  hospital  June  29.  There  was  a  well-marked  rash,  the 
tonsils  were  swollen,  with  patches  of  exudation  ;  there  were  two  or  three  degrees  of  fever 
for  a  few  days.  Discharged  August  20.  He  vomited  August  21  ;  admitted  August  25 
with  a  typical  attack  of  scarlet  fever.  There  was  a  well-marked  rash,  tonsillitis,  and 
fever. 

Scarlet  fever  is  apparently  not  so  infectious  as  measles — a  large  number  of 
children  and  adults  escape  being  attacked  ;  thus  Biedert  found  in  an  epidemic 


250^ 


The  Specific  Fevers 


which  prevailed  in  an  isolated  village  (Neunhofen)  where  the  inhabitants 
freely  mixed  with  one  another,  and  where  no  isolation  of  the  fever  patients 
was  possible,  that  about  58  per  cent,  of  the  children  unprotected  by  a  former 
attack  contracted  the  disease,  though  only  about  two-thirds  of  these  had  well- 
marked  symptoms,  the  rest  having  sore  throats  only.  In  different  epidemics 
the  number  attacked  varies  extremely. 

The  mortality  varies  in  different  epidemics  ;  thus,  in  the  fever  ward  of 
the  Children's  Hospital,  Manchester,  it  has  varied  from  6  to  25  per  cent,  in 
different  years  ;  during  the  years  1873-1897,  the  average  mortality  among 
3,319  cases  treated  was  12  per  cent.  During  the  eighteen  years  1 880-1 897 
(inclusive)  2,840  cases  were  treated  with  an  average  mortality  of  9"6  per  cent. 
This  average  mortality  closely  corresponds  with  the  figures  given  by  Collie 
of  the  mortality  in  the  London,  Stockwell,  and  Homerton  fever  hospitals, 
where,  in  upwards  of  10,000  cases  of  scarlet  fever,  the  mortality  was  i2-5 
per  cent.  As  in  all  probability  many  of  the  milder  cases  of  fever  never 
come  into  hospital  at  all,  10  per  cent,  mortality  given  by  W.  Squire  as  the 
average  appears  to  be  as  .  nearly  correct  as  possible.  Age  influences  the 
mortality  very  considerably  ;  the  mortality  is  high  during  the  first  three  or 
four  years  of  life,  amounting  to  25  to  30  per  cent.  ;  it  continues  high  till  the 
age  of  five  or  six  years  is  reached,  declining  after  this  till  the  age  of  twenty- 
one,  again  increasing  after  this  epoch. 


Table  showing  mortality  in  2,840  cases 

of  scarlet  fever  at  different  ages. 

- 

Boys       Deaths 

Per  cent. 

Girls 

Deaths 

Per  cent. 

Total 

Deaths 

Per  cent. 

Under  2yrs. 

2-5    M 

S-io  M 
10-14  ,, 

70 
481 
628 
174 

15 
80 

31 

4 

21-4 
i6-6 

4'9      1 

2  "2        ; 

82 
489 
686 
230 

27 

66 

46 

6 

32-9 

I3'4 

67 

2-6 

152 
970 

1314 
404 

42 
146 

n 
10 

27 '6 
IS 

5-3 
2-4 

1353      1    130 

9-6        li    1487 

14s 

97 

2840 

275 

9-6 

Are  there  any  morbid  conditions  of  body  which  predispose  to  scarlet 
fever?  Very  little  is  definitely  known  about  such  conditions  ;  individual  sus- 
ceptibility varies  in  the  most  erratic  manner,  or  at  least  is  governed  by  no 
known  laws,  and  it  cannot  be  said  that  ill-health  in  any  way  either  favours 
or  protects  from  attacks.  To  this,  however,  must  be  added  that  it  is  our 
experience  that  operation  cases  and  surgical  cases  with  open  wounds  are 
more  liable  to  contract  the  disease  than  are  healthy  children.  The  so-called 
surirical  scarlet  fever  is  simply  scarlet  fever  occurring  in  a  surgical  case 
(vide  infra). 

The  strong  and  healthy  appear  to  be  as  frequently  attacked  as  the 
weakly,  and  the  attacks  are  often  fatal  to  such  ;  it  is  by  no  means  uncommon 
to  see  on  'Ocve^  post-mortem  table  children  who  have  succumbed  to  malignant 
scarlet  fever  looking  fat  and  plump,  and  who  were  apparently  in  the  best  of 
health  when  attacked. 

The  transference  of  infection  from  the  sick  to  the  healthy  takes  place  in 
various  ways  ;  it  may  be  by  direct  contact,  the  breath  or  the  exhalations  from 
the  fever  patient  may  be  inhaled,  or  it  may  be  cairied  by  means  of  clothes 


Scarlet  Fever  2  5  i 

or  wearing  apparel  or  bedding  which  has  been  in  contact  with  the  sick.  It 
is  highly  probable  also  that  the  excretions  of  the  patient  are  infective,  the 
urine,  fteces,  and  discharges  from  the  ear  or  nose.  The  poison  of  scarlet 
fever  appears  to  retain  its  vitality  for  many  months,  fever  breaking  out  again 
and  again  in  houses  which  have  been  imperfectly  disinfected.  One  of  the 
common — but  often  unsuspected — sources  of  infection  in  schools  and  the 
general  population,  is  the  number  of  individuals  who  have  had  mild  and 
unrecognised  attacks  mixing  with  others  and  so  spreading  the  infection. 

Incubation. — Mostly  two  to  five  days,  though  it  maybe  much  less,  perhaps 
only  a  few  hours  ;  forty-eight  to  seventy-two  hours  is  a  common  period,  but 
in  many  cases  where  slight  sore  throat  precedes  for  some  hours  the  more 
definite  symptoms  it  is  impossible  to  state  the  period  of  incubation  with 
exactness.  In  the  majority  of  cases,  if  the  initial  vomiting  be  taken  as  the 
first  symptom,  it  will  be  found  that  the  incubation  is  under  three  days.  It 
cannot  be  said  with  certainty  that  it  may  not  be  more  than  five  days,  but 
such  cases  must  be  very  exceptional. 

Premonitory  Symptoms. — The  invasion  in  the  case  of  children  is  usually 
sudden,  the  first  symptom  being  nearly  always  vomiting  ;  this  may  come  on 
after  a  hearty  meal.  There  may  also  be  diarrhoea.  In  older  children  and  in 
adults  there  is  usually  nausea  if  not  vomiting,  sore-throat,  headache,  shivering, 
and  loss  of  appetite.  '  Sore-throat '  with  vomiting  in  a  child  or  adult  is  ex- 
tremely suspicious  of  scarlet  fever,  especially  if  fever  is  present.  The  tem- 
perature usually  runs  up  quickly  to  103°  or  104°,  and  perhaps  the  patient 
sits  over  the  fire  on  account  of  feeling  chilly  ;  in  some  cases  there  is  slight 
delirium.  An  attack  of  vomiting  and  diarrhoea  coming  on  suddenly  with 
feverishness  (io3°-io4°  F.)  is  very  probably  the  commencement  of  scarlet 
fever,  and  in  such  cases  death  may  take  place  within  twenty-four  hours  of 
the  onset. 

Symptoms  and  Course. — Medium  Forms. — The  premonitory  symptoms 
are  usually  followed  within  twenty-four  hours  by  the  characteristic  rash. 
This  is  said  to  make  its  appearance  first  about  the  neck,  but  there  is  no  cer- 
tainty about  this,  and  traces  may  be  seen  of  it  on  the  backs  of  the  hands  and 
wrists,  or  on  the  thighs  or  abdomen,  when  it  is  present  nowhere  else.  In 
some  cases  it  is  first  visible  on  the  back.  At  first  the  rash  is  faint  though 
perfectly  characteristic,  taking  two  or  three  days  to  reach  its  height.  In 
other  cases  it  disappears  in  the  course  of  twenty-four  or  forty-eight  hours, 
having  at  no  time  been  more  than  a  fine  faint  rash.  When  typical  it 
cannot  be  mistaken  for  any  other  rash.  Viewed  from  a  short  distance,  the 
whole  body  excepting  the  face  is  of  a  uniform  bright  red  colour  ;  examined 
closely,  it  consists  of  a  multitude  of  red  points  which  correspond  with  the  hair 
follicles  ;  these  points  are  surrounded  by  zones  of  erythematous  redness  which, 
joining  with  one  another,  give  a  general  diffuse  red  appearance  to  the  skin. 
Sometimes  the  rash  consists  of  the  points  only  without  the  erythema  ;  in  this 
case  the  redness  is  necessarily  less  vivid.  In  rough  skins  the  rash  may  be 
coarsely  punctiform  ;  that  is,  there  is  a  condition  of  '  goose  skin,'  each  point 
being  large  and  the  rash  therefore  coarse.  Sudamina  are  not  uncommon. 
In  other  cases  the  rash  is  patchy  on  the  limbs,  and  when  this  is  so,  the  case 
may  simulate  measles  ;  the  patches  consist  of  clusters  of  fine  papules  or  points 
with  much  surrounding  erythema,  while  normal  skin  is  present  between  the 


252 


The  Specific  Fever's 


patches.  Sometimes  the  rash  is  haemorrhagic,  minute  extravasations  of 
blood  taking  place  into  the  skin  ;  this  may  occur  in  mild  cases.  It  is,  how- 
ever, much  more  common  in  malignant  cases.  Purpuric  patches  are  not 
uncommonly  found  after  death  that  were  not  present  during  life.  Towards 
the  end  of  the  first  week  the  rash,  which  has  been  fading  for  several  days,  is 
succeeded  by  desquamation,  which  is  free  or  slight  according  to  the  intensity 
of  the  rash.  This  exfoliation  of  the  epidermis  generally  goes  on  for  many 
weeks,  being  present  longer  about  the  hands  and  feet.  The  tonsils  are  red, 
swollen,  and  covered  with  an  excess  of  mucoid  secretion,  yellow  points 
corresponding  to  the  tonsillar  crypts  are  usually  present,  sometimes  there 


Fig.  49. — Temperature  Chart  of  a  case  of  Scarlet  Fever,  medium  attack.      M.K.,  aged.   13  years 

*,  Rash  present. 


are  patches  of  yellow  exudation  ;  the  soft  palate,  uvula,  and  pharynx  are  more 
or  less  congested.  The  nasal  mucous  membrane  is  frequently  involved,  so 
that  there  is  much  discharge  from  the  nose.  The  deep  cervical  glands  at 
the  angles  of  the  jaw  are  usually  enlarged.  The  tongue  is  coated  with  a 
thick  white  fur  ;  not  infrequently  there  is  a  dry  glazed  central  band  on  the 
dorsum  ;  in  the  course  of  a  few  days  the  tongue  cleans,  leaving  a  red  clean 
glazed  tongue  with  prominent  fungiform  papillae — i.e.  '  the  strawberry  tongue.' 
The  eyes  are  often  suffused  and  the  conjunctivae  injected,  and  with  this  there 
is  often  sleeplessness  or  delirium,  no  doubt  due  to  a  congested  state  of  the 
membranes  of  the  brain.  In  rare  cases  the  delirium  is  severe  and  the 
patient  violent. 


Scarlet  Fever  253 

The  pulse  is  quick,  varying  from  1 20  to  1 50,  often  faster  than  the  temperature 
or  the  general  state  of  the  child  would  have  led  one  to  expect  ;  the  tempe- 
rature varies,  mostly  reaching  103°  or  105°  in  a  moderately  sharp  attack 
(fig.  49).  The  urine  is  scanty,  high-coloured,  and  often  contains  a  small 
quantity  of  albumen.  In  the  course  of  a  few  days,  perhaps  by  the  end  of  the 
third  or  fourth,  the  attack  has  reached  its  height,  and  the  symptoms  begin  to 
decline.  The  rash  gradually  fades,  the  temperature  falls,  the  evening  rises 
being  smaller  and  the  morning  remissions  more  marked  ;  the  tongue  cleans, 
the  fauces  are  less  injected,  and  the  appetite  returns.  By  the  end  of  the  first 
week  the  temperature  has  reached  normal  ;  any  feverishness  which  continues 
after  this  suggests  some  complication,  the  commonest  being  an  ulcerating  or 
sloughy  process  going  on  in  the  throat,  inflammation  of  glands,  and  otitis.  It 
must,  however,  be  added  that  attacks  of  scarlet  fever  are  extremely  unequal 
and  no  two  cases  are  exactly  alike. 


DAY 

1 

2 

3 

4 

5 

6 

102 

101 

100 

99 

98 

97 

96 
PULSE 

1 

1 

^ 

.1 

1 

1 

i 

1 

1 

1 

A 

J^ 

« 

/■ 

\ 

1 

y 

r 

\ 

A 

A 

V 

^ 

S»^ 

i 

\j 

» 

; — 

Tk 

V 

^ 

' — 

I 

— 

V 

^ 

V 

/^ 

!i^ 

V 

V 

^ 

0 

0 

CO 
00 

Fig.  50. — Temperature  Chart  of  a  Mild  Scarlet  Fever.     B.  W. ,  aged  3  years. 
Attack  contracted  in  scarlet  fever  ward. 

IMCild  Scarlet  Pever. — In  some  cases  the  premonitory  symptoms  are 
absent  or  the  fever  is  only  slight  and  easily  overlooked,  and  the  first  thing  to 
call  attention  to  the  attack  is  the  rash.  It  not  unfrequently  happens,  even 
in  hospitals  where  the  children  are  under  observation,  that  the  discovery  of 
a  rash  is  the  first  thing  noted.  The  child  may  seem  to  be  in  its  usual  health, 
make  no  complaint  of  sore  throat,  and  appear  to  take  its  meals  well,  with 
an  evening  rise  and  a  morning  remission  of  temperature,  and  yet  be  suffering 
from  a  mild  attack  of  scarlet  fever  (fig.  50).  The  rash  in  such  cases  is  rarely 
well  marked,  but  if  it  is  diffuse  and  punctiform  and  remains  visible  for  twenty- 
four  or  forty-eight  hours,  the  attack  is  unmistakably  one  of  scarlet  fever. 
There  is  usually  slight  tonsillitis.  We  have  seen  a  few  cases  that  undoubtedly 
suffered  from-scarlet  fever  and  infected  others,  but  who  never  had  a  tempera- 
ture above  99°  Fahr.,  but  had  a  fairly  typical  rash.  The  most  difficult  cases  to 
diagnose  are  those  where  there  is  sore  throat  without  rash,  inasmuch  as 
there  is  nothing  characteristic  about  a  scarlatinal  tonsillitis. 


254 


The  Specific  Fever's 


Maligrnant  Scarlet  Pever. — In  some  cases  death  occurs  very  rapidly, 
perhaps  within  twenty-four  hours,  though  this  is  rare.  The  most  rapid  case 
which  has  come  under  our  notice  was  that  of  a  girl  of  twenty  months. 

Scarlet  Fever  rapidly  fatal. — She  was  noticed  not  to  take  her  dinner  well,  and  vomited 
after  her  tea ;  her  temperature,  which  had  been  normal  in  the  morning,  had  risen  to  103° 
by  5'3o  (fig.  51  a)\  at  7  p.m.  the  pulse  was  i5o,  the  tonsils  were  enlarged,  and  there  was 
a  very  faint  rash  over  the  body  ;  she  was  removed  the  same  evening  by  the  resident  medical 
officer,  Dr.  Kershaw,  to  the  fever  ward.  Next  morning  the  rash  had  disappeared,  the 
tonsils  were  enlarged  with  a  patch  of  exudation  on  one  of  them,  her  pulse  and  respirations 
were  rapid,  but  she  did  not  seem  extremely  ill.  She  gradually  became  worse,  the  face 
cyanosed,  respiration  gasping,  and  pulse  failing  ;  she  died  soon  after  5  P.M.,  twenty-four 
hours  after  the  initial  symptom  of  vomiting. 


^m^'h£^5^S^B^5^S^5SS^B^5i5B  ^SMJ^S^S^B^S^S^S^SiHHiHi^vHiiH^H 


Fig.  51  a. — Temperature  Chart  of  Malignant 
Scarlet  Fever.     Death  in  twenty-four  hours. 


Fig.  51 15.— Temperature  Chart  of  Malignant 
Scarlet  Fever.    Death  seventh  day.     *,  Kash. 


At  the  post-mortem  one  tonsil  was  sloughing  and  soft.  Death  in  this 
case,  as  in  most  rapidly  fatal  cases,  took  place  through  the  heart  failing 
under  the  influence  of  the  poison  ;  they  may  not  appear  for  a  few  hours  in 
actual  danger,  then  symptoms  of  cyanosis  and  collapse  set  in,  quickly  followed 
by  a  fatal  result.  In  the  great  majority  of  acute  cases  death  does  not  take 
place  till  the  fourth  or  the  seventh  day  (fig.  5 1  <^) ;  in  these  the  temperature 
is  high,  perhaps  105°  or  106°,  there  is  much  diarrhoea,  often  extreme  restless- 
ness, followed  by  coma  ;  the  tonsils  are  much  swollen  and  covered  with  foul 


Scarlet  Fever  255 

secretion,  there  is  much  nasal  discharge,  the  glandular  swelling  and  cellulitis 
are  great,  the  neck  being  hard  and  tense  to  the  touch  ;  the  skin  is  of  a  dull 
lurid  colour,  the  extremities  cold,  and  the  heart  gradually  fails.  If  life  is 
prolonged  for  a  few  days  the  tonsils  and  soft  palate  slough  and  the  lungs 
become  the  seat  of  septic  pneumonia.  In  another  class  of  cases  in  which 
life  is  prolong-ed  to  the  end  of  the  second  or  third  week  a  condition  of 
septicsemia  is  set  up.  The  tonsils  ulcerate,  sloughy  patches  appear  on  the 
fauces,  the  glands  become  enlarged  and  brawny,  the  nasal  mucous  membrane 
discharges  a  purulent  secretion,  and  the  conjunctiva  become  affected  ;  the 
temperature  is  remittent  but  continues  high,  the  urine  albuminous,  pus  wells 
out  from  both  ears,  the  child  gradually  wastes,  and  dies  in  the  course  of  ten 
or  fourteen  days.  K\  \h^  post-mortem  \h&xQ  are  found  extensive  sloughing 
about  the  fauces,  pleuro-pneumonia,  and  large  hasmorrhagic  kidneys  with 
minute  abscesses.  In  some  cases  the  temperature  remains  high  during  the 
second  or  even  third  week  without  any  local  lesion  being  discoverable  to  ac- 
count for  it.  In  all  such  cases  the  lungs  should  be  carefully  examined,  and  the 
possibility  of  some  septic  inflammation  going  on  in  the  kidneys  should  be 
borne  in  mind. 

Prognosis. — A  guarded  prognosis  must  always  be  given  in  the  case  of 
young  children,  the  throat  complications  in  these  being  generally  serious.  The 
tonsils  are  apt  to  slough,  and  they  have  so  little  power  to  get  rid  of  the  foul 
secretion  which  rapidly  forms  in  the  pharynx  and  nose  that  they  are  extremely 
liable  to  pneumonia  from  extension  from  the  pharynx  and  glandular  inflam- 
mation. Diarrhoea  is  always  a  serious  symptom  ;  when  present  at  the  onset 
it  points  to  a  sharp  attack,  in  the  later  stages  it  is  also  of  evil  augury,  and  if 
a  marked  symptom  it  usually  presages  a  fatal  result.  Drowsiness  at  the  onset 
and  during  the  course  of  the  attack  is  an  unfavourable  symptom,  as  it  usually 
accompanies  a  high  degree  of  fever  and  a  severe  course.  In  all  cases  where 
the  temperature  is  maintained  during  the  second  or  third  week  the  prognosis 
must  be  exceedingly  guarded,  and  the  possibility  of  a  fatal  nephritis  super- 
vening must  be  borne  in  mind. 

Complications  and  SeqitelcE. — Many  of  these  have  already  been  referred  to  : 
(i)  The  tonsils  may  become  deeply  excavated,  the  soft  palate  may  slough, 
a  small  hole  appearing  through  the  velum,  to  be  followed  perhaps  by  an  almost 
entire  destruction  of  the  soft  parts  ;  in  the  rare  cases  when  recovery  follows 
cicatrisation  and  deformity  of  the  soft  palate  are  the  result.  The  inflamma- 
tion may  spread  to  the  epiglottis  and  larynx,  and  croupy  symptoms  become 
so  urgent  that  tracheotomy  is  required.  The  fauces  and  larynx  may  become 
the  seat  of  false  membrane.  In  rare  cases  the  ulcerating  process  in  the  throat 
may  reach  and  enter  the  internal  carotid  or  jugular  vein  and  death  follow  from 
haemorrhage. 

(2)  The  nasal  and  conjunctival  mucous  membrane  may  be  the  seat  of 
inflammation  or  a  fibrinous  exudation.  A  chronic  discharge  from  the  nose 
and  a  consequent  eczematous  condition  of  the  upper  lip  may  be  left  after  the 
fever. 

(3)  Otitis. — The  inflammation  may  spread  along  the  Eustachian  tube  to 
the  middle  ear,  and  dus  be  formed  in  the  tympanic  cavity,  which  finds  its  exit 
by  perforation  of  the  membrane.  This  may  happen  during  the  fever  or  during 
convalescence.     We  have  known  it  occur  as  early  as  the  fourth  day,  in  other 


256 


The  Specific  Fevers 


cases  when  convalescence  is  well  established.  Suppuration  in  the  tympanum 
is  one  of  the  common  causes  of  a  continued  elevated  temperature  after  the 
disappearance  of  the  rash  ;  the  child  may  suffer  very  little  pain,  and  the  pre- 
sence of  pus  in  the  external  meatus  or  staining  the  hnen  may  be  the  first 
thing  to  call  attention  to  this  complication.  At  other  times  the  child  will  put 
its  hand  to  its  ear  and  frequently  shake  its  head,  as  if  to  get  rid  of  some  source 
of  irritation.  Pyaemia  and  abscesses  in  the  lungs  may  follow  if  thrombosis  of 
the  lateral  sinus  occurs. 

(4)  The  cervical  grlands  frequently  become  enlarged  and  suppurate, 
either  during  the  course  of  the  fever  or  when  the  child  is  convalescent.  In 
some  cases,  more  especially  in  weakly  children,  much  sloughing  may  go  on 
about  the  neck,  deep  ragged  ulcers  being  formed,  exposing  the  large  vessels  ; 
fatal  haemorrhage  may  occur  from  the  latter. 

(5)  Broncbo-  or  pleuro-pneumonia  occurs  very  frequently  during 
the  second  week,  and  is  due  to  extension  downwards  of  the  lesion  from 
the  throat.  Pneumonia  followed  by  empyema  may  take  place  during  con- 
valescence. 

(6)  Synovitis  and  Rbeumatism. — The  joints  are  apt  to  become  swollen 
and  tender  at  the  end  of  the  first  or  beginning  of  the  second  week  ;  those 
most  frequently  affected  are  the  wrists  and  small  joints  of  the  hand,  whilst 
sometimes  the  synovial  sheaths  of  the  tendons  at  the  back  and  in  the  palms 
of  the  hands  are  attacked.  The  knees,  ankles,  soles  of  the  feet,  elbows,  and 
joints  of  the  cervical  vertebrse  may  be  affected.  Movement  of  the  affected 
joints  causes  pain,  and  they  are  mostly  swollen,  red,  and  tender.  The  affec- 
tion is  rarely  severe,  being  fugitive,  and  seldom  returning  to  the  same  joint. 
The  knees  sometimes  remain  swollen  for  some  weeks  from  effusion  into  the 
joints.  The  cases  complicated  with  synovitis  are  usually  severe,  though 
exceptions  occur.  Peri-endocarditis  occurs  much  less  frequently  than  in  the 
ordinary  form  of  rheumatism.  Synovitis  sometimes  occurs  in  association 
with  nephritis  during  the  second  week.  Attacks  of  true  rheumatism  are  apt 
to  occur  during  convalescence,  but  such  are  more  common  in  young  adults 
than  in  children  ;  these  attacks  differ  in  no  particular  from  ordinary  rheu- 
matism, the  heart  being  frequently  involved.  An  attack  of  scarlet  fever 
during  convalescence  from  rheumatism  not  infrequently  causes  a  relapse. 

Between  the  years  1 880  and  1 897,  inclusive,  1 03  cases  of  synovitis  occurred 
in  the  2,840  patients  treated  at  Pendlebury  for  scarlet  fever  (3-5  per  cent.). 
The  following  table  shows  the  frequency  of  this  complication  in  boys  and 
girls  at  various  ages  : 


Boys 

j       ■                            Girls 

Age  in  years 

Cases  of  S.F. 

Cases  of 
Synovitis 

Per  cent. 

Cases  of  S.  F. 

Cases  of       |p,,^gnt. 
Synovitis 

0-2 

2-5 

S-io 

10-14 

70 
481 
628 
174 

I 

14 

21 

2 

I '4 
2-9 

3 '3 
II 

82 
489 
686 
230 

3 
II 

39 
12 

3-6 

2-2 

5-6 

5'2 

Total 

1353 

38 

2-8 

1487 

65 

4 '3 

Scarlet  Fever  257 

It  uill  thus  be  seen  that  joint  affections  in  scarlet  fever  are  moie  common 
in  girls  than  in  boys,  in  the  proportion  of  3  to  2  relatively.  According  to 
the  course  of  the  affection  this  complication  of  scarlet  fever  may  be  divided 
into  regular,  irregular^  and  complicated  syiiovitis. 

Regular  Synovitis. — Seventy  of  the  103  cases  of  synovitis  ran  a  regular 
course,  passing  off  in  53  instances  in  from  two  to  six  days,  and  only  lasting 
beyond  ten  days  in  4  cases.  In  41  of  these  regular  cases  the  synovitis 
came  on  before  the  end  of  the  first  week,  and  in  62  before  the  eleventh  day 
of  the  scarlet  fever.  The  joints  involved  varied  greatly,  but  in  22  instances 
the  hands  and  wrists  only  were  affected,  and  in  28  other  ciises  these  same 
joints,  along  with  others,  were  tender  and  swollen.  The  frequency  with 
which  the  other  joints  were  affected,  either  alone  or  as  part  of  a  multiple 
synovitis,  was  knees  19,  ankles  13,  elbows  10,  shoulders  8,  feet  6.  Pain  and 
stiffness  were  felt  in  the  back  and  neck  by  9  patients. 

The  condition  of  the  sounds  of  the  heart  in  these  regular  cases  was  noted 
as  normal  53  times.  A  temporary  apex  systolic  bruit  developed  in  15 
cases,  from  the  fifth  to  the  twelfth  day  of  the  fever,  and  persisted  varying 
lengths  of  time  from  two  days  to  nine  weeks,  but  usually  for  about  seven  to 
ten  days.  In  two  instances  a  bruit  was  present  when  the  case  left  the 
hospital.  As  a  rule  no  exacerbation  of  temperature  was  noticed  to  be  coincident 
with  the  onset  of  the  synovitis.  In  50  cases  the  scarlet  fever  pyrexia  was 
prolonged  beyond  ten  days,  though  it  did  not  often  rise  above  102.  All  these 
regular  cases  recovered. 

Irregular  Syiiovitis. — In  addition  to  the  above  cases  of  regular  synovitis 
there  were  14  (10  girls  and  4  boys)  which  ran  a  more  or  less  irregular 
course,  though  all  recovered  eventually.  In  6  cases  the  joints  were  not 
affected  until  after  the  eighteenth  day  of  the  fever,  and  in  3  instances  the 
pains  were  in  the  limbs  and  not  limited  to  the  joints.  In  6  cases  the 
synovitis  persisted  for  periods  ranging  between  twelve  and  sixty-one  days, 
and  the  pyrexia  in  the  majority  of  the  cases  was  prolonged  to  between  four- 
teen and  130  days.  Three  cases  were  considered  to  be  true  rheumatism. 
A  temporary  systolic  murmur  developed  in  5,  and  a  permanent  bruit  in  3 
of  these  cases. 

Complicated  Synovitis. — The  remaining  19  of  the  103  cases  were  com- 
plicated by  serious  affections  which  teminated  fatally  in  11  instances. 
Thirteen  cases  were  below  five  years  of  age,  and  of  these  8  died.  The 
complications  which  ended  fatally  were  pyaimia  3,  septicsemia  2,  cellulitis  i, 
malignant  scarlet  fever  i,  scarlet  fever  anginosa  i,  meningitis  i,  and  nephritis 
2  ;  those  which  recovered  were  nephritis  with  suppuration  in  foot  i,  purpura 
hasmorrhagica  i,  pneumonia  and  empyema  i,  acute  epiphysitis  of  the  right 
femur  I,  and  sj'novial  suppuration  4.  Pus  developed  in  one  or  other  joint 
in  12  of  the  cases. 

(7)  Pysemia  and  suppuration  in  the  joints  occasionally  occurs  ; 
any  joint  may  be  affected.  Such  cases  are  mostly  fatal,  though  not 
invariably  so. 

(8)  Pericarditis  or  endocarditis  may  occur  without  joint  pain  or 
nephritis  being  present. 

(9)  TJephritis. — No  complication  of  scarlet  fever  can  vie  in  importance 
or  interest  with  nephritis  ;  and  this  condition  often  gives  rise  to  much  anxiety 

S 


258  The  Specific  Fevers 

in  an  otherwise  mild  and  favourable  case.  The  'initial'  albuminuria  which 
frequently  accompanies  the  febrile  state  in  the  first  week  of  the  disease  is  not 
of  much  importance,  as  it  is  usually  temporary  and  not  due  to  any  important 
lesion  of  the  kidneys,  and  quickly  disappears  as  the  fever  subsides  towards 
the  end  of  the  first  week.  Apart  from  this  febrile  albuminuria,  there  are  two 
forms  of  nephritis  which,  it  is  important  to  bear  in  mind,  are  distinct  from 
one  another,  though  they  have  frequently  been  confounded  and  much  con- 
fusion has  arisen  in  consequence.  They  may  be  distinguished  as  {a)  Septic 
nephritis,  {b)  Post-scarlatinal  nephritis. 

{a)  Septic  Nephritis. — In  the  severe  forms  of  fever  comphcated  with 
sloughing  tonsils  and  soft  palate  and  much  glandular  sweUing  the  urine  is 
albuminous,  frequently  highly  so  ;  but  it  rarely  contains  blood  in  appreciable 
quantities  or  casts  ;  there  are  indeed  no  renal  symptoms,  or  if  there  are 
they  are  so  masked  by  the  general  condition  of  septicemia  that  it  is  difficult 
or  impossible  to  differentiate  them.  There  is  no  dropsy  or  uraemic  pheno- 
mena. If  the  patient  survive  till  the  end  of  the  second  or  third  week,  a 
more  or  less  typical  pysemic  kidney  is  found  at  the  post-mortem.  The 
kidneys  are  enlarged,  frequently  very  much  so  ;  they  are  flabby,  of  a  cream 
colour  on  the  surface,  with  minute  hccmorrhages  and  usually  minute  ab- 
scesses. On  section  the  cortex  is  of  the  same  cream  colour  mottled  with 
injected  vessels  and  points  of  fluid  or  inspissated  pus.  This  condition  of 
kidney  forms  part  of  a  general  condition  of  pyaemia,  and  is  chiefly  of  interest 
in  demonstrating  that  the  kidneys  suffer  during  the  course  of  the  disease 
itself,  and  consequently  in  cases  which  recover  are  in  a  condition  which  pre- 
disposes to  inflammatory  affections  during  convalescence. 

{U)  Post-scarlatinal  TTephritis. — This  is  the  form  which  is  liable  to  super- 
vene during  the  third  or  fourth  week,  and  which  is  known  generally  by  the 
name  of  scarlatinal  nephritis.  There  can  be  little  doubt  that  the  kidneys  are 
actively  engaged  during  the  course  of  the  fever  itself,  and  for  the  succeeding 
week  or  two,  in  carrying  off  the  toxines  formed  during  the  fever,  and  are 
in  an  irritable  condition  and  prone  to  take  on  inflammatory  action,  in 
the  same  way  as  the  bronchial  tubes  and  lungs  are  left  in  an  irritable  con- 
dition after  measles  and  are  apt  to  suffer  from  inflammatory  attacks  :  and 
while  it  is  possible  in  both  cases  that  nephritis  and  pneumonia  may  super- 
vene in  spite  of  the  greatest  care,  yet  any  chill  or  exposure  to  cold  is  extremely 
likely  to  produce  or  determine  such  an  attack.  The  number  of  those  who 
suffer  varies  in  different  epidemics,  and  also  according  to  the  season  and 
the  care  which  is  taken  of  them  during"  convalescence.  Taking  an  average 
of  several  years,  we  find  about  6  per  cent,  of  our  hospital  patients  have 
suffered  from  post-scarlatinal  nephritis.  Patients  who  have  had  the  primary 
fever  both  in  a  severe  and  mild  form  may  be  attacked  ;  in  the  former  class 
of  cases,  especially  where  there  has  been  no  period  of  apyrexia,  it  is  mostly 
fatal  ;  in  the  latter  class — at  least  in  hospital — it  is  rarely  so  fatal.  The 
prognosis  is  usually  bad  in  those  cases  where  the  temperature  continues 
elevated  during  the  second  week,  in  consequence  of  severe  pharyngeal  or 
glandular  inflammation,  and  which  contract  nephritis  in  the  third  week,  the 
latter  complication  supervening  on  the  throat  lesions.  From  the  fourteenth 
to  the  twenty- sixth  (lay  is  the  commonest  time  for  nephritis  to  supei'vene, 
but  as  it  usually  begins  insidiously,  traces  of  albumen  being  present  for  a 


Scarlatinal  Nephritis 


259 


few  days  before  blood  and  larger  quantities  of  albumen  appear,  it  is  often 
impossible  to  determine  the  exact  date  of  the  commencement  of  the  attack. 
In  well-marked  cases  it  is  noticed  by  the  attendants  that  the  child  which, 
since  the  subsidence  of  the  fever,  has  been  practically  well,  becomes  restless, 
feverish  at  night,  thirsty,  has  a  quick  perhaps  hard  pulse,  and  passes  small 
quantities  of  dark-coloured  urine.  If  particular  attention  has  been  paid  to 
the  urine,  it  will  probably  have  been  found  that  it  has  been  diminishing  in 
quantity,  and  has  contained  small  quantities  of  albumen  for  a  few  days  prior 
to  the  dark  urine  being  passed.  Sometimes  pufifiness  about  the  face  pre- 
cedes the  appearance  of  albumen  in  the  urine.  The  urine  may  be  dark 
red,  but  usually  it  is  'smoky,'  and  on  allowing  it  to  stand  in  a  tall  glass 
deposits  a  dark  flocculent  precipitate,  not  unlike  the  flocculi  in  beef  tea.  This 
precipitate  consists  of  blood  corpuscles,  epithelium  and  fibrinous  cylinders 
which   have  been    formed    in   the    tubules    and    consequently   may  contain 


^BIBIiEIBIDBiQDDBBDBQQEIBI^SlJ^BiBISIQQQQIJH 


Fig.  52 


-Temperature  Chart  of  Post-scarlatinal  Nephritis, 
convulsions.     Recovery. 


'■',  rash  ;  a,  albumen  ;  c,  urjemic 


corpuscles  and  epithelium.  The  supernatant  liquid  contains  a  variable 
amount  of  albumen,  sometimes  becoming  almost  solid  on  being  boiled  ; 
more  often  a  half  to  a  sixth  of  its  volume  of  coagulated  albumen  pre- 
cipitates by  boiling.  It  may  not  contain  any  blood.  For  a  few  days  the 
urine  continues  dark  and  albuminous  and  of  high  specific  gravity  (1020- 1025), 
and  diminished  in  quantity,  perhaps  only  a  few  ounces  per  diem  ;  the  face 
becomes  pale  and  pufTy,  there  may  be  oedema  of  the  feet  and  scrotum,  and 
more  or  less  vomiting  ;  then,  perhaps,  at  the  end  of  a  week  an  improvement 
takes  place,  large  quantities  of  urine  are  passed  with  diminished  quantities 
of  blood  and  albumen,  and  the  child  becomes  again  convalescent,  though 
the  urine  may  contain  some  albumen  for  weeks  or  even  months,  and  the 
anaemia  may  continue  for  a  like  period.  On  the  other  hand,  in  a  minority  of 
cases  the  nephritis  is  prolonged  and  symptoms  of  uraemia  may  supervene, 
the  pulse  becomes  slow,  the  temperature  subnormal,  the  tongue  dry  and 
brown.     Often  there  is  frequent  vomiting,  sometimes  diarrhoea  (see  fig".  52)  ; 


26o  The  Specific  Fevers 

haemorrhages  may  take  place  from  various  surfaces,  especially  the  nose  ; 
there  may  be  amaurosis,  muscular  twitchings,  and  perhaps  general  con- 
vulsions. 

In  all  cases  of  nephritis  particular  care  should  be  taken  to  examine  the 
heart,  inasmuch  as  a  fatal  result  is  more  often  brought  about  in  consequence 
of  cardiac  failure   than  directly  through  uraemic  convulsions.     One  of  the 
effects  of  nephritis  is  to  raise  the  tension  in  the  blood-vessels,  and  this,  if 
continued  for  any  considerable  time,  is  followed  by  dilatation  of  the  beart, 
the  tension  in  the  arterial  system  in  combination  with  malnutrition  being 
responsible  for  this  result.     Another  not  uncommon  result  is  endocarditis 
or  pericarditis,  and  possibly  embolism.     The  possibility  of  death  occur- 
ring- suddenly  during   the  course  of  an  acute  or  subacute  nephritis  must 
always  be  borne  in  mind  ;  the  patient  may  appear  to  be  doing  fairly  well, 
perhaps  sitting  up  in  bed  and    playing  with  his   toys,   when   an  attack  of 
dyspnoea  comes  on,  the  face  becomes  livid  or  pallid,  the  pulse  disappears,  and 
death  quickly  takes  place.     Sometimes  attacks  of  dyspnoea  may  precede  by 
a  day  or  two  the  fatal  event.     Such  cases  have  been  often  described  as  being 
fatal   in  consequence  of  oedema  of  the  lungs,  the  dilatation  of  the  heart 
having  been  overlooked  ;  oedema  of  the  lungs  is  present,  but  it  is  secondary 
to  the  cardiac  failure.     The  pathology  of  such  cases  is  tolerably  clear ;  acute 
nephritis,  running  a  very  rapid  course  in  consequence  of  the  kidneys  being 
almost  completely  choked,  usually  terminates  with  uraemic  phenomena  ;  if 
it  runs  a  slower  course,  the  tension  in  the  blood-vessels  throws  additional 
work  upon  the  heart,  the  left  ventricle  struggles  with  the  increased  work 
thrown  upon  it,  the  blood  becomes  impoverished  and  nutrition  impaired, 
the  cavities  of  the  heart    dilate,  and  finally   that  organ    gives    way,   often 
suddenly  at  the  last.     The  amount  of  dilatation    present  should  be   care- 
fully noted  by  the  position  of  the  apex  beat,  and  the  increase  of  impaired 
resonance. 

Pneumonia,  pleurisy,  and  peritonitis  may  occur  in  the  course  of 
nephritis,  and  pleuro-pneumonia,  ending  in  gangrene,  may  take  place.  In  a 
few  cases  the  attack  is  exceedingly  acute,  the  temperature  being  high,  104° 
to  105°,  the  tongue  dry  and  brown,  the  urine  containing  much  blood  and 
albumen,  and  death  rapidly  taking  place.  In  such  cases  there  is  usually 
coincident  pneumonia.  In  a  large  number  of  cases  the  attacks  are  mild, 
a  small  quantity  of  albumen,  perhaps  without  any  blood,  making  its  appear- 
ance during  the  third  week,  the  face  becoming  puffy  and  the  child  ansemic, 
the  albumen  disappearing  in  the  course  of  a  week  or  two,  and  the  child  after 
a  prolonged  convalescence  slowly  regaining  its  health. 

Total  suppression  of  urine  is  not  common,  a  few  ounces  daily  being 
usually  passed  ;  in  one  of  our  cases  only  three  ounces  of  pale  albuminous 
urine  was  passed  in  the  four  and  a  half  days  which  preceded  death  ;  there 
were  no  convulsions.  Life  is  rarely  prolonged  beyond  the  fifth  day  if  there 
is  total  suppression.  Death  takes  place  in  many  cases  without  convulsions  ; 
in  others  convulsions  may  supervene  and  recovery  follow  ;  the  convulsions 
are  not  dependent  only  upon  retained  urinary  products,  but  also  upon  the 
stability  of  the  nervous  centres,  which  differs  markedly  in  different  children. 
Diagtiosis. — The  diagnosis  of  mild  cases  of  scarlet  fever  often  presents 
extraordinary  difficulty,  and  yet  the  importance  of  making  a  diagnosis  is  often 


Diagnosis  of  Scarlet  Fever  261 

great.      In  hospital  or  dispensary  practice  cases  have  mostly  to  be  treated  as 
infectious   or  non-infectious  ;    as  there  is  often  no  opportunity  of  taking  a 
middle  course,  they  must  be  sent  into  a  fever  ward  with  the  risk  of  contract- 
ing the  disease  if  the  diagnosis  is  at  fault,  or  of  infecting  others   if  treated 
with  non-infectious  cases.     In  private  practice  among  the  wealthier  classes 
it  may  be  possible  to  isolate  all  suspicious  cases,  but  such  are  always  a  source 
of  an.xiety.     It  cannot  be  too  forcibly  impressed  that  diagnosis    in    some 
instances  is  impossible,  and  that  errors  will  occasionally  be  made  by  the  most 
experienced,  though  at  the  same  time  it  must  be  acknowledged  that  mistakes 
are  more  frequently  made  through  carelessness  than  from  any  want  of  know- 
ledge.   The  most  characteristic  phenomenon  is  of  course  the  rash,  and  if  this 
is  well  marked,  being  diffuse  and  punctiform,  and  lasting  at  least  twenty-four 
or  forty-eight  hours,  even  in  the  absence  of  tonsiUitis  or  a  high  temperature, 
there  can  hardly  be  a  doubt  about  the  diagnosis.    Mild  cases  of  scarlet  fever 
may  occur  with  a  temperature  never  rising  above  99°  F.     A  measles  rash 
can  hardly  be  mistaken  for  it,  except  in  those  cases  where  the  rash  is  patchy 
about  the  limbs,  but  in  these  it  is  usually  diffuse  and  characteristic  on  the 
trunk.    A  scarlet  fever  rash,  however  faint,  usually  lasts  for  twenty-four  hours 
at  least,  in  this  respect  differing  from  erythematous  rashes,  which  may  be 
present  in  the  evening  and  gone  before  morning.     It  is  always  well  when 
called  to  see  a  rash  by  artificial  light  to  wait  for  daylight   to  give  a   definite 
opinion.     It  is  important  to  bear  in  mind  that  a  rash  more  or  less  resembling 
scarlet  fever  occurs  in  some  cases  of  pytemia  and  septicaemia,  also  in  diph- 
theria (which,  when  it  occurs,  is  septic),  influenza,  and  rubella.     A  red  rash 
is  sometimes  caused  by  belladonna,  arsenic,  and  cjuinine.     To  distinguish 
between  scarlatinal  and  simple  tonsiUitis  is  mostly  impossible  in  the  absence 
of  a  rash  ;  the  '  strawberry '  tongue  is  generally  absent  in  cases  unattended 
with  a  rash.    Cases  of  tonsillitis  where  the  nasal  mucous  membrane  becomes 
involved,  or  where  there  is  excessive  exudation  on  the  fauces  or  sloughing  of 
the  soft  palate,  if  chphtheria  can  be  excluded,  are  probably  scarlatinal.    If  the 
lymphatic  glands  at  the  angle  of  the  jaw  become  enlarged  and  tender,  scarlet 
fever  is  probable.     Acute   nephritis  occurring  after  an  anomalous   rash  or 
sore  throat  makes  it  practically  certain  that  the  primary  attack  was  scarlet 
fever. 

Much  importance  has  been  attached  in  the  past  to  desquamation  as 
a  means  of  diagnosis.  Now  while  a  typical  case  of  scarlet  fever  desquamates 
freely,  the  epidermis  separating  in  flakes  from  the  skin  of  the  neck,  trunk. 
fingers,  toes,  &c.,  some  of  the  milder  cases  hardly  desquamate  at  all,  the  skin 
only  becomes  slightly  roughened  ;  while  on  the  other  hand  cases  of  pneu- 
monia, enteric  or  any  febrile  disease,  will  desquamate  more  or  less.  The 
absence  of  desquamation  does  not  prove  that  there  has  been  no  scarlet  fever, 
and  the  presence  of  more  or  less  desquamation  by  no  means  proves  that  there 
has  been  scarlet  fever.  The  presence  of  desquamation  taken  in  conjunction 
with  a  history  of  a  sore  throat,  or  associated  with  nephritis,  will  materially 
help  the  diagnosis. 

Morbid  AnatoDiy. — In  the  bodies  o  those  dying  during  the  first  few  days 
of  the  disease,  no  gross  lesions  except  those  in  connection  with  the  throat 
can  be  detected.  One  or  both  tonsils  are  ragged,  perhaps  sloughy,  the  glands 
are  enlarged,  perhaps  beginning  to  suppurate,  the  internal  organs  are  gorged 


26?  The  Specific  Fevers 

with  blood,  there  ai-e  minute  hcemorrhages  on  their  surfaces.  The  heart, 
Uver,  and  kidneys  are  pale,  the  Peyer's  glands  are  swollen,  and  the  mucous 
membrane  of  the  intestines  injected.  If  the  child  has  survived  a  week  or 
more,  usually  septic  changes  are  present ;  the  lungs  are  in  a  condition  of 
pneumonia  more  or  less  advanced,  which  is  secondary  to  the  sloughy  throat 
and  the  glandular  inflammation  and  cellulitis  in  the  neck  ;  marked  changes 
are  also  found  in  the  kidneys  if  the  child  has  survived  two  or  three  weeks. 
In  typical  cases  these  are  much  enlarged,  flabby,  pale  on  the  surface,  with 
minute  hsemorrhages  and  injected  capillaries  ;  on  section  minute  abscesses 
may  often  be  seen  at  the  base  of  the  pyramids.  On  microscopical  examina- 
tion large  tracts  of  kidney  substance  will  be  found  infiltrated  with  leucocytes, 
and  micrococci  {Streptococci pyogenes)  will  be  detected  in  the  capillaries.  If 
death  has  been  the  result  of  post-scarlatinal  nephritis,  in  the  early  stages  the 
kidneys  will  be  gorged  with  blood  and  deeply  stained  in  consequence  of  the 
tubules  being  choked  with  casts  and  the  capillaries  distended  to  their  utmost. 
In  a  later  stage  the  kidneys  are  enlarged  and  pale,  dripping  urine  on  section, 
and  on  close  exammation  it  will  be  noted  that  the  Malpighian  bodies  are 
enlarged  and  pale,  standing  out  prominently  like  grains  of  sand  dusted  on  to 
the  cortex.  On  microscopical  examination  it  will  be  found  that  the  glomeruli 
are  enlarged  in  consequence  of  containing  an  increase  in  the  number  of  their 
nuclei,  in  some  cases  fibrinous  thrombi,  and  in  a  later  stage  being  surrounded 
by  a  fibro-cellular  growth  which  completely  strangulates  them  and  produces 
complete  obstruction.  When  nephritis  is  present  the  cavities  of  the  heart 
are  found  dilated  ;  sometimes  there  is  peri-endocarditis,  peritonitis,  or  pneu- 
monia. 

No  specific  micro-organism  has  been  discovered  in  cases  of  scarlet  fever, 
yet  we  cannot  doubt  that  such  exists.  One  of  the  reasons  for  its  non-dis- 
covery is  in  all  probability  that  it  will  not  grow  on  any  of  the  ordinary 
cultivation  media.  There  is  no  difficulty  in  cultivating  various  pus  cocci 
from  a  drop  of  blood  taken  from  the  finger  of  a  scarlet  fever  patient,  but 
this  is  also  true  of  measles  and  other  febrile  diseases. 

Treatment. — As  soon  as  scarlet  fever  is  suspected,  means  must  be  adopted 
to  prevent  the  spread  of  the  disease  in  the  household  by  isolating  the  patient 
as  far  as  it  is  possible  to  do  so.  It  is  obviously  impossible  to  effect  this  in  the 
smaller  class  of  houses,  and  indeed  even  in  large  and  well-appointed  houses 
nothing  like  perfect  isolation  can  be  carried  out,  the  removal  of  the  patient  to 
a  fever  hospital  being  in  all  cases  the  wisest  course  when  it  can  be  managed. 
To  diminish  risks  of  infection  as  far  as  it  is  possible,  a  room  on  the  upper 
story  should  be  secured,  or,  still  better,  the  whole  of  the  top  landing  should 
be  devoted  to  the  patient  and  those  of  the  household  who  are  in  attendance 
on  him.  Every  article  in  the  room  which  can  be  spared,  especially  cur- 
tains, carpets,  and  other  woollen  goods,  should  be  removed,  only  retaining 
such  as  are  required  for  immediate  use.  The  bedding  should  consist  of  a 
horsehair  mattress  and  warm  but  light  coverings.  The  sick-room  should 
be  large  and  airy,  the  more  cubic  space  the  better,  provided  it  can  be  kept  at 
a  moderate  temperature,  and  all  draughts  avoided.  The  attendants  on  the 
sick  should  not  mix  with  the  other  members  of  the  household,  but  devote 
themselves  entirely  to  the  work  of  the  sick-room.  If  there  are  children  in 
the  house  Avho  have  not  had  scarlet  fever,  the  question  will  arise  what  is  best 


Treatment  of  Scarlet  J^ever  263 

to  be  done  with  tlieni.  In  the  first  place,  it  is  clear  that  they  must  not^attend 
school  or  mix  with  other  children  ;  the  question  of  sending  them  away  must 
depend  upon  various  circumstances.  Remaining  at  home  unquestionably 
involves  a  risk,  and  at  any  time  so  long  as  the  house  remains  infected  they 
may  be  attacked.  Sending  them  away  involves  the  risk  of  their  being  incu- 
bating at  the  time,  and  of  conveying  the  infection  to  another  household. 
The  best  course,  if  it  can  be  taken,  is  to  send  them  away  to  some  household 
where  there  are  no  children,  and  whence  they  can  be  brought  back  if  they  are 
attacked  after  removal.  To  send  them  away  to  distant  seaside  lodgings 
could  not  be  sanctioned  under  any  circumstances  ;  it  is  better  to  run  the  risk 
of  infection  at  home,  than  have  them  sicken  away  from  home  among 
strangers,  and  become  the  source  of  an  outbreak  elsewhere. 

As  soon  as  the  diagnosis  of  scarlet  fever  is  made  the  child  should  be  put 
to  bed,  and  remain  there  as  long  as  there  is  fever,  or,  still  better,  for  three 
weeks,  though  this,  in  mild  cases  especially,  is  difficult  to  enforce  in  private 
practice.  In  hospital  practice  three  weeks  in  bed  is  the  ordinary  rule  ;  the 
object  of  this  being  to  obviate  the  risk  of  catching  cold,  and  it  is  better  to 
be  over-cautious  in  this  respect.  The  diet  for  the  first  few  weeks  should 
consist  largely  of  fluids  ;  it  is  most  important  that  the  digestive  organs  should 
not  be  over-taxed  and  that  the  excretory  apparatus,  especially  the  kidneys, 
should  be  active,  inasmuch  as  the  waste  products  are  increased  during  fever, 
and  the  poison  also  passes  out  of  the  body  in  this  way.  During  the  febrile 
period,  milk  and  barley  water  or  milk  and  soda  water  is  the  best  food  that 
can  be  given  ;  feverish  children  rarely  care  for  beef  tea,  and  all  jellies  and 
meat  e.xtracts  are  unnecessary.  One  or  two  pints  of  milk  suitably  diluted 
during  the  twenty-four  hours  will  be  quite  sufficient  ;  if  more  is  attempted, 
sickness  may  not  unlikely  be  produced.  Daily  sponging  with  tepid  or  cold 
water,  to  which  some  Condy's  Fluid  or  other  deodorant  is  added,  is  of  much 
service.  Hot  baths  are  useful  during  convalescence,  but  the  bath  must  be 
brought  to  the  patient's  bedside.  Whilst  desquamation  is  proceeding, 
after  the  spongings  or  warm  baths  the  skin  should  be  gently  anointed  with 
glycerine  and  starch,  weak  carbolic  oil,  or  ung.  lanolini  with  carbolic  acid  or 
eucalyptus. 

We  have  no  belief  whatever  in  the  possibility  of  rendering  the  patient 
■entirely  free  from  infection  by  anointing  the  skin.  We  believe  the  infection 
of  the  disease  is  given  out  from  the  nose  and  throat  rather  than  by  the  skin. 

The  application  of  topical  remedies  to  the  throat  and  nasal  mucous 
membrane  is  frequently  a  matter  of  great  difficulty  in  children,  and  much 
adroitness  and  firmness  will  be  often  required.  In  mild  cases  where  there 
is  only  a  slight  congestion  and  swelling  of  the  tonsils,  no  local  treatment 
need  be  attempted,  except  perhaps  the  sucking  of  pieces  of  ice  or  iced  milk. 
In  older  children  the  throat  spray  may  be  used  if  the  patient  is  sufficiently 
docile,  but  young  children  are  almost  sure  to  offer  a  certain  amount  of 
resistance  when  their  throat  is  being  attended  to,  and  under  these  circum- 
stances spraying  is  useless,  as  the  spray  is  rarely  properly  directed.  Here 
mopping  by  means  of  a  large  paint  brush  or  lint  secured  at  the  end  of  a 
piece  of  stick  will  have  to  be  resorted  to.  Irrigating  the  mouth  and  fauces 
is  useful  in  clearing-  away  the  mucus  and  septic  matters  which  are  apt  to 
accumulate.      If  there  is  free  discharge  of  purulent  matters  from  the  nose, 


264  The  Specific  Fevers 

gentle  irrigation  is  of  undoubted  value,  and  we  think  no  harm  can  be  done  as 
some  have  stated. 

In  selecting  an  antiseptic  which  is  to  be  used  freely  as  in  irrigating  or 
spraying,  it  is  well  to  remember  that  some  of  it  may  be  swallowed,  and 
consequently  it  should  not  be  very  poisonous,  while  for  mopping  or  painting 
a  caustic  or  more  active  poison  may  be  used.  In  severe  cases  the  frequent 
cleansing  of  the  throat  is  a  matter  of  great  importance  and  one  upon  which 
we  are  incUned  to  lay  much  stress  ;  it  is,  however,  often  attended  with 
exhausting  struggles  for  the  patient,  and  can  only  be  done  by  properly 
trained  nurses,  the  friends  rarely  having  the  necessary  skill  or  firmness. 
The  actual  antiseptic  selected  is  of  less  importance  than  the  manner  of  using 
it,  the  object  being  to  prevent  the  mucus  and  products  of  decomposition  from 
accumulating  in  the  fauces  and  being  drawn  into  the  air  passages  or  being 
absorbed.  For  syringing  the  nose  and  fauces  a  warm  solution  of  boric  acid 
(i  in  20),  a  weak  solution  of  iodine  (2  drachms  of  the  tincture  ot  iodine  to 
10  ounces),  or  solution  of  liq.  sodee  chlorinatae  (i  to  20),  answer  as  well  as 
any,  and  are  not  disagreeable.  For  mopping  a  saturated  solution  of 
boroglyceride  in  glycerine,  a  saturated  solution  of  salicylic  acid  in  sp. 
vini  rect.,  or  glycerine  acid  carbolici  (l  in  10)  may  be  used  with  ad- 
vantage ;  it  is  well  to  clear  away  the  mucus  and  purulent  discharge  before 
mopping  the  fauces. 

There  is  but  little  reason  to  believe  that  the  course  of  the  fever  is  much 
influenced  by  internal  remedies  ;  in  mild  cases  a  saline  such  as  citrate  of 
potash  is  useful,  giving  it  in  doses  of  2  to  5  grs.  every  four  or  six  hours  ; 
chlorate  of  potash  is  of  doubtful  value.  In  more  severe  cases  the  treatment 
must  be  adapted  to  the  symptoms,  stimulants  being  usually  required  on  account 
of  the  depression  which  is  so  often  present.  Carbonate  of  ammonia,  digitalis, 
cinchona  bark,  separately  or  in  combination,  are  the  most  useful  drugs. 
Diarrhoea,  if  excessive,  must  be  kept  in  check  by  opium  enemata  ;  if  moderate, 
it  had  better  be  left  alone.  Sleeplessness,  headache,  delirium,  are  best 
relieved  by  an  ice  bag  to  the  head  and  full  doses  of  bromide.  We  do 
not  believe  that  biniodide  of  mercury  or  other  mercurial  salt  is  of  the 
slightest  use  in  modifying  the  severity  of  the  attack.  It  has  failed  entirely 
in  our  hands.     (F.  46,  47). 

When  the  temperature  continues  high,  being  104°  to  105°,  quinine  in  i  to 
3  gr.  doses,  and  repeated  packs,  so  as  to  get  the  skin  to  act,  have  appeared 
to  us  the  most  useful  form  of  treatment.  The  child  should  be  wrapped  up  in 
a  sheet  wrung  out  of  water  at  60°  and  rolled  up  in  a  blanket  for  an  hour. 
This  must  be  repeated  if  the  temperature  continues  high.  Cold  spongings 
are  also  useful.  In  the  early  stages  especially,  graduated  baths  are  of  great 
value  in  reducing  temperature  and  soothing  the  patient.  The  patient  should 
be  put  into  a  bath  of  90°  and  the  temperature  of  the  bath  gradually  reduced  by 
the  addition  of  cold  water.  In  the  later  stages,  especially  when  there  is 
blueness  about  the  lips  and  the  heart  flagging,  more  care  is  necessary,  and 
we  have  seen  serious  depression  produced  by  a  too  long  use  of  a  cold  bath. 
Phenacetin  and  antipyrin  are  not  suitable  for  serious  cases,  on  account  of  the 
depression  they  are  apt  to  produce. 

The  injection  of  anti-streptococcus  serum  has  been  resorted  to  in  cases 
of  scarlet  fever  of  the  septic  type,  i.e.  sloughing  throat  and  glandular  enlarge- 


Treatment  of  Scarlet  Fever  265 

mcnt  ;  10  to  20  c.c.  is  the  usual  dose.  Successful  cases  have  been  reported 
by  Mamnoreck  and  Knyvett.  Our  own  limited  experience  has  not  been 
very  favourable.  Oxygen  gas  has  been  used  with  advantage  by  Cresswell/ 
and  we  have  been  well  pleased  with  it  in  some  cases  in  which  we  have 
tried  it. 

It  must,  however,  be  admitted  that  the  treatment  of  the  severer  forms  of 
scarlet  fever  is  disappointing  and  often  disheartening  ;  in  spite  of  the  most 
devoted  nursing,  stimulants  freely  given,  antipyretics,  liquid  nourishment  of 
all  kinds,  antiseptics  to  the  fauces,  they  go  from  bad  to  worse,  apparently  un- 
influenced by  all  that  has  been  done  for  them.  On  the  other  hand,  it  some- 
times happens  that  cases  which  at  first  are  most  unpromising  are  apparently 
saved  by  careful  nursing  and  appropriate  treatment,  and  this  fact  should 
encourage  every  effort.  In  rare  instances  sloughing  fauces  will  mend,  pneu- 
monias clear  up,  temperatures  which  have  been  high  for  two  or  even  three 
weeks  gradually  fall,  and  complete  recovery  ensue. 

The  otitis  which  so  commonly  occurs  is  usually  suppurative  from  the 
first  ;  the  tympanic  membrane  quickly  gives  way  and  a  free  discharge  follows. 
Earache  should  be  treated  by  the  instillation  of  warm  camphorated  oil  to 
which  a  drop  or  two  of  laudanum  has  been  added,  and  hot  fomentations 
may  be  applied  externally.  A  single  drop  of  glyc.  acid,  carbolici  (B.P.), 
carefully  dropped  into  the  ear  so  as  to  reach  the  membrane,  usually  gives 
relief  If,  on  examination  with  the  speculum,  pus  is  seen  bulging  the  mem- 
brane, an  incision  should  be  made  ;  but  nature  usually  anticipates  the 
surgeon  in  this  matter,  and  so  quickly  that  the  operation  is  seldom  necessary, 
except  in  those  cases  where  the  membrane  fails  to  give  way  early.  The  pus 
which  forms  in  scarlet  fever  appears  to  penetrate  the  membrane  more  quickly 
than  the  pus  formed  in  non-febrile  cases.  When  a  discharge  exists,  care 
should  be  taken  to  keep  the  ear  syringed  out,  and  some  antiseptic  powder, 
such  as  iodoform  and  boracic  acid,  blown  in.  The  after-treatment  of  chronic 
otitis  need  not  be  gone  into  here. 

The  preventive  treatment  of  post-scarlatinal  nephritis  consists  in  the 
greatest  care  being  taken  during  the  second  and  third  weeks  to  avoid  cold  and 
to  keep  the  skin  acting,  and  to  avoid  a  stimulating  diet  and  any  overfeeding. 
The  child  should  be  sponged  daily  or  bathed,  provided  there  is  no  risk 
of  chill  ;  the  diet  should  be  chiefly  fluid,  milk,  light  puddings  and  sops,  and 
the  bowels  should  be  acted  upon  if  necessary  by  laxatives  or  salines  such  as 
tartrate  of  soda  or  Glauber's  salts.  On  the  appearance  of  albumen  a  smart 
purge  of  senna  or  jalap  should  be  given,  and  the  child  dressed  in  a  flarmel 
night  shirt  and  placed  between  the  blankets,  salines  such  as  citrate  of 
potash,  liq.  ammon.  acet.,  or  tartrate  of  soda,  being  given.  The  diet  should 
consist  entirely  of  barley  water  and  of  milk,  or  at  any  rate  of  fluids.  Hot 
packs,  a  blanket  wrung  out  of  hot  water  being  used,  or  hot  vapour  baths 
given  by  means  of  Allen's  apparatus,  or  warm  baths,  are  always  useful  in 
acting  on  the  skin  and  drawing  away  the  blood  from  the  kidneys,  and  so 
relieving  the  inflammatory  congestion  present.  The  smaller  the  quantity  of 
urine  passed  the  more  vigorous  should  be  the  packs  or  baths.  Ten  grains 
of  jaborandi  leaves,  made  into   an    infusion    with  hot  water,  or  one-tenth 

1  Practitioner,  October  1888. 


266  TJie  Specific  Fevej-s 

of  a  grain  of  nitrate  of  pilocarpine  subcutaneously,  may  be  given  before 
the  packs  once  or  twice  a  day.  Children  bear  pilocarpine  well,  but  its  use 
requires  care  on  account  of  the  cardiac  depression  it  is  apt  to  produce. 
Poultices  to  the  loins  should  be  applied  between  the  packs.  Dry  cupping 
seems  sometimes  to  be  useful  and  may  be  tried.  If  the  kidneys  fail  to  act, 
and  no  urine  or  only  a  small  quantity  is  secreted,  large  enemata  of  warm 
water  will  s'ometimes  give  relief,  urine  being  passed  as  the  enema  is  being 
expelled. 

During  the  course  of  a  nephritis  the  condition  of  the  heart  must  be 
carefully  watched,  as  also  must  any  tendency  to  muscular  twitchings  about 
the  face  or  hands.  Any  attacks  of  dyspnoea  or  evidence  of  cardiac  dilatation 
must  be  met  by  the  administration  of  digitalis,  two  to  five  drops  every  two 
hours.  Solution  of  nitro-glycerine  in  drop  doses,  inhalation  of  chloroform, 
or  nitrate  of  amyl  may  be  tried  if  convulsions  supervene. 

Quarantine. — Six  weeks  at  least — better  two  months — reckoning  from 
the  first  day  of  the  fever  should  elapse  before  a  child  convalescent  from 
scarlet  fever  can  be  allowed  to  rejoin  his  companions  or  go  to  seaside 
lodgings  ;  and  not  then  if  the  desquamation  is  incomplete  or  there  is  a  dis- 
charge from  his  nose  or  ears.  In  so  important  a  matter  as  discharging  a 
convalescent  scarlet  fever  patient,  it  is  wise  to  err  on  the  side  of  caution. 

Experience  shows  that  the  scarlatinal  infection  sticks  to  the  patient  with 
extraordinary  tenacity',  as  the  number  of  return'  cases  to  infectious  hospitals 
show.  Putting  aside  the  question  of  desquamation  (which  has  probably  been 
too  exclusively  regarded)  and  also  of  purulent  discharge  of  ears,  it  seems 
certain  that  the  infection  clings  to  scarlatinal  patients  for  a  considerable 
period,  and  this  in  spite  of  many  carbolic  baths  and  much  head  washing. 
It  seems  likely  that  the  scarlet  fever  micro-organisms  remain  in  the 
convalescent's  nose  and  throat  long  after  he  is  apparently  well,  and  if  he 
mixes  with  his  fellows  he  may  infect  them.  It  is  not  wise  to  send  a  patient 
direct  from  the  sick-room  or  hospital  ward  to  mix  with  others.  Wherever 
it  is  possible  there  should  be  a  convalescent  ward,  and  the  patient  should 
spend  many  hours  in  the  open  air  before  being  looked  upon  as  safe. 

Measles 

Measles  is  an  acute  infectious  disorder  characterised  by  coryza,  cough, 
and  fever  in  the  prodromar stage,  followed  by  a  peculiar  papular  eruption  on 
the  face  and  body. 

Measles,  like  whooping  cough,  prevails  in  widespread  epidemics,  though 
its  epidemics  are  of  shorter  duration  ;  but  sporadic  cases  are  always  occur- 
ring in  large  centres  of  population.  This  epidemic  prevalence  occurs  in  large 
cities  every  eighteen  months  or  two  years,  though  the  epidemics  differ  very 
much  in  their  extent  and  fatality. 

When  once  the  disease  enters  a  household,  or  indeed  a  city  street  or 
alley,  hardly  any  of  the  inhabitants  escape  except  perhaps  the  young  infants, 
and  those  protected  by  a  previous  attack  ;  the  chief  sufferers  are  young 
children.  When  introduced  into  the  ward  of  a  children's  hospital  the 
majority  of  those  who  are  not  protected  will  probably  be  attacked.  Infants 
under  six  months  appear  less  susceptible  than  children  over  that  age  ;  though 


Measles  267 

infants  are  occasionally  born  with  the  rasli  of  measles  on  them.'  Communi- 
ties removed  from  frequent  contact  with  ci\  ilisation,  and  where  there  has 
been  no  epidemic  prevalent  for  some  time  previously,  invariably  suffer 
severely  when  the  poison  of  measles  is  introduced,  adults  being  affected  as 
well  as  children.  The  most  notable  instance  of  this  in  recent  times  is  the 
epidemic  of  measles  in  the  Fiji  Islands  in  1875,  ^^hich  raged  for  four  months, 
40,000  natives  dying  out  of  a  population  of  150,000,'-  equal  to  upwards  of  one 
in  every  four  of  the  population,  whereas  in  London  in  1886,  which  may  be 
taken  as  an  average  year,  the  deaths  from  measles  were  five  in  every  10,000 
living  (at  all  ages).  The  same  \irulence  of  an  epidemic  may  be  seen  in  a 
lesser  degree  in  populations,  more  especially  among  children,  in  villages  or 
isolated  places  where  there  has  been  no  epidemic  for  some  time  previously. 
The  susceptibility  to  measles  is  exceedingly  great  in  unprotected  subjects  ; 
thus  Biedert,-^  in  a  small  epidemic  in  an  isolated  village,  found  only  14  per 
cent,  of  the  children  who  were  unprotected  escaped  after  being  exposed  to 
the  infection.  In  the  Faroe  Islands  under  similar  conditions  only  4-5  per 
cent,  and  i  per  cent,  escaped.*  The  same  experience  obtains  in  schools  and 
in  the  wards  of  children's  hospitals,  where,  if  a  child  has  been  admitted 
incubating  and  remains  till  the  rash  appears,  an  epidemic  follows,  which 
it  is  difficult  to  stop  until  nearly  all  of  the  unprotected  have  been 
attacked.  The  epidemics  are  independent  of  season,  and  occur  in  winter  as 
in  summer. 

The  disease,  like  most  other  specific  fevers,  spreads  by  contagion,  but  the 
nature  of  this  has  not  been  satisfactorily  determined,  though  micro-organisms 
have  been  obtained  from  the  breath  and  secretions  of  patients  suffering 
from  measles  by  A.  Ransome,  Braidwood  and  Vacher,  and  Canon  and 
Pielicke.  We  have  frequently  made  cultivations  of  pus  cocci  from  the 
blood  of  patients  with  measles^  and  such  can  also  be  detected  by  staining  a 
dried  drop  of  blood. 

The  poison  is  apparently  given  off  in  the  breath  and  other  secretions,  and 
may  be  conveyed  to  a  distance  by  its  adhering  to  the  clothes  or  person  of  a 
nurse  or  others  coming  in  contact  with  the  sick.  The  infection,  however, 
appears  to  be  more  diffusible  or  more  readily  destroyed  than  the  poison  of 
smallpox  or  varicella,  as  rarely  if  ever  in  our  experience  is  it  introduced  into 
a  ward,  except  by  those  who  were  admitted  incubating,  it  being  unlike  variola 
or  varicella  poison  in  this  respect,  infection  in  the  latter  case  appearing  to  be 
brought  in  by  visitors.  The  infection  is  known  to  be  given  out  from  the  patient 
very  early  in  the  attack — that  is,  from  the  first  appearance  of  definite 
symptoms,  as  coryza  and  fever — but  there  is  good  reason  to  believe 
that  Mr.  Vacher  is  right  in  believing  that  measles  is  mfectious  during 
the  incubative  stage,  as  well  as  during  the  febrile  and  eruptive  stages. 
Several  instances  which  point  strongly  to  this  conclusion  have  come  under 
our  notice. 

The  mortality  differs  enormously  according  to  the  circumstances  under 
which  the  attacks  develop  and  also  in  difterent  epidemics.  In  healthy 
children  among  the  well-to-do  class  the  mortality  is  small  ;  in  the  tubercular 

'   Helm,  Medical  Chronicle,  May  1890.  -  Corney,  quoted  by  Collie. 

3  Jahrbuch  fiir  Kinderheilkunde,  vol.  xxiv.  p.  94.  ^  Madsen,  Panum. 

■''  Brit.  Med.  Jour.  April  23,  1892. 


268 


The  Specific  Fevers 


and  wasted  children  to  be  found  in  workhouses,  hospitals,  and  among  the 
lower  classes  the  mortality  is  enormous,  no  disease  more  certainly  being 
attended  with  a  fatal  result.  William  Squire  places  it  at  20  to  30  per  cent, 
of  those  attacked  in  crowded  wards.  Among  dispensary  patients  the 
mortahty  generally  amounts  to  9  or  10  per  cent.  In  our  own  dispensary, 
during  the  six  years  1880-1885,  1,395  cases  were  treated,  with  128  deaths, 
making  a  mortality  of  9  per  cent.  Of  the  fatal  cases  T2,  P^r  cent,  were  under 
two  years  of  age,  and  9  per  cent,  under  six  months  of  age. 

Second  attacks  of  true  measies  are  not  uncommon.  We  know  one 
family  in  which  one  boy  has  had  a  severe  attack  of  measles  four  times,  a 
boy  and  girl  three  times  each,  and  one  girl  twice  ;  all  these  attacks  were 
severe.  In  many  cases  where  there  is  said  to  have  been  a  recurrence  of 
measles,  one  of  the  attacks  has  no  doubt  been  rubella. 


MBHBBHHHBHHflHHHB 


■■ill 
■■ill 
■■■II 

Mill 


I^BIHIIil 
■■■■I^IUI 
l>S?JiH»ll 


■Ml 


Fig.  53- — Temperature  Charts  of  cases  of  Measles.     '■■',  rash  present. 


Incubation. — When  inoculated  this  appears  to  be  seven  or  eight  days, 
when  contracted  in  the  usual  way  it  is  mostly  ten  to  twelve  days,  the  rash 
appearing  on  the  fourteenth  or  sixteenth  day. 

Symptoms.  Pj'odromal  Stage. — The  early  symptoms  are  those  of  a 
feverish  cold.  The  child  sneezes,  waters  at  the  eyes,  there  is  catarrh  of  the 
nasal  membrane,  with  usually  a  hard,  hacking  or  perhaps  croupy  cough. 
Sometimes  the  symptoms  are  those  of  a  catarrhal  laryngitis  or  bronchitis. 
The  palpebral  conjunctivae  are  suffused  and  of  a  pink  colour  from  congestion 
of  the  capillary  vessels.  The  child  is  feverish,  often  acutely  ill,  the  tempera- 
ture rising  in  the  evening  a  degree  or  two  and  usually  falling  again  in  the 
morning  ;  this  continues  though  becoming  increasingly  marked,  till  the  rash 
is  fully  developed.     Sometimes  there  is  a  marked  remission  on  the  second  or 


Measles 


269 


third  day  (see  fig.  54).  An  examination  of  the  fauces  will  show  that  the 
tonsils,  hard  and  soft  palate,  are  I'eddened,  and  often  distinct  papules  or  red 
points  surrounded  by  a  zone  of  congestion  are  visible  ;  in  the  slighter  cases 
these  papules  are  absent.  This  papular  rash  is  present  some  twenty-four  to 
forty-eight  hours  before  the  rash  appears  on  the  face  and  trunk.  Koplik  ' 
has  pointed  out  that  at  this  stage,  that  is  a  day  or  two  before  the  appearance 
of  the  external  rash,  small  irregular  spots  of  a  bright  red  colour  maybe  seen 
on  the  mucous  membrane  of  the  cheeks  and  inside  of  the  lips.  In  a  good 
light  a  'bluish  white  speck'  may  be  seen  in  the  centre  of  each  spot.  He 
believes  these  spots  to  be  diagnostic  of  measles.  Earache  is  common  during 
the  prodromal  stage. 


BiWI— — ■■■ 

■Ib  1  i  s  iaa  s^BS  iBiBB  B 

^I^^H 

^^^^1 

^^^^H 

^^^^H 

^■lifiHl^       ■■                            ^IM^        ■'■^^^■1       ^Hi^^HH^^        1^ 

^^^^H 

^^^^H 

^^^^H 

^^^IH 

^BBR 

^Z^^B 

^^^^H 

^■^■h     ■■                  iiiHuwi     F  iHiiia     ■■     '^mmm^^ammum     mm 

^^^^H 

^^^■■l       ■■                          lat^'B'              ■»!■       Ill       ^^BB^^^^       B 

^^^^H 

^■IShI      H                      IbWh           Hril      11      MBIHHHHiH      ■ 

^^^^1 

^^^^H 

^^^BB 

^^■■■■■■^                                 IIIBBIITI        HI             ■■!       IIIHa^^^^^       B 

^H^^l 

^■ffiB^BlH                          ITI^           ■             ■!      IIIHHHnHHI      S 

^BbH 

■■BBS                 UB                S'    ISIBBBBBB    B 

^^^^H 

^^^^H 

■■bBB                SB                B    SBffi^BBBB^ 

^^^^H 

^^^^H 

j^^^^H 

^^^^H 

^^^■^■■^              'H     I        ^^                                  ^'Mi^^lM^^^I        B 

^^^BB 

JBB^I 

^Vr^B 

^^^^H 

^BEfiBHi^BI              ^BB        BiiiB                            IH^III^H^IB^BH^        ■■ 

^^^^H 

^BIB^^^              ■■■■        ^^               HH^BII^IIIBHW^BBBB^^        ■■ 

^^^^H 

^^^^■i^l^^       ^^       IB^                        ■IIMHW^IWiHA^^BBia       ^ 

^^^^H 

^^^^H 

9 

bh 

^^1 

^^^^H 

^^^^H 

^H 

Fig.  54. — Temperature  Chart  of  a  case  of  Measles,  complicated  with  Broncho-pneumonia. 

*,  rash. 

Eruptive  Stage. — The  characteristic  eruption  usually  makes  its  appear- 
ance at  the  end  of  the  fourth  day,  on  the  forehead,  face,  neck,  and 
fauces.  The  child's  appearance  at  this  time  is  so  characteristic  that  in 
well-marked  cases  a  glance  is  sufficient  to  establish  the  diagnosis.  The 
face  is  flushed,  the  eyes  red  and  watering,  there  is  a  short  cough,  the  fore- 
head, nose,  and  cheeks  are  covered  with  crops  of  dusky  red  papules,  sur- 
rounded by  a  zone  of  erythema  which  contrasts  with  the  normal  skin 
between  the  groups.  The  papules  can  be  distinctly  seen  and  felt,  and 
though  not  '  shotty '  to  the  touch,  yet  they  have  often  a  distinct  feeling  of 
hardness.  The  rash  on  the  face  is  usually  both  patchy  and  discrete,  the 
1  Arc/lives  of  Pediatrics,  Dec.  1896. 


2/0  The  Specific  Fevers 

patches  being  made  up  of  confluent  papules,  the  latter  of  small  groups  or 
single  papules  arrar.ged  at  times  in  small  crescents  or  semicircles.  In 
the  course  of  a  day  or  two  the  rest  of  the  body  is  more  or  less  covered  with 
the  rash  ;  it  is  apt  to  be  confluent  with  much  erythematous  redness  on  the 
dependent  surfaces,  the  extensor  surfaces  of  the  arm  and  thigh,  the  back 
and  buttocks,  and  more  discrete  or  spotty  on  the  chest  and  rest  of  the  body. 
By  the  fifth  or  sixth  day  the  eruption  is  at  its  height,  and,  beginning 
to  fade  first  on  the  face  and  later  on  the  body  and  limbs,  is  followed, 
especially  on  the  face,  by  a  fine  desquamation.  By  the  seventh  or  eighth 
the  rash  has  completely  disappeared,  leaving  at  most  only  an  indefinite 
mottling  or  staining  over  the  body.  The  temperature,  which  has  probably 
reached  103°  to  105°  by  the  sixth  day,  quickly  falls  to  normal  or  thereabouts, 
and  the  headache  and  discomfort  are  gone  and  the  child  seems  greatly 
relieved.  In  severe  cases  in  weakly  children  the  crisis  may  be  accompanied 
by  much  exhaustion,  but  this  rarely  happens.  The  temperature  remaining 
high  indicates   some   complication  such  as  bronchitis  or   pneumonia  (see 

fig-  54)- 

Mild  or  ill-defined  IMeasles.— Very  often  all  the  symptoms  are  milder 
than  those  just  described,  but  at  the  same  time  are  perfectly  characteristic. 
On  the  other  hand,  the  attack  may  be  so  slight  as  to  be  recognised  with  diffi- 
culty. There  may  be  almost  an  entire  absence  of  symptoms  in  the  prodromal 
stage,  or  a  temperature  only  reaching  100°  or  101°,  the  coryza  and  catarrh 
being  insignificant,  while  the  rash  is  represented  by  ill-defined  and  character- 
less papules  about  the  neck,  back  of  the  hands,  and  thighs.  In  other  cases 
probably  the  catarrh  and  laryngeal  symptoms  are  well  marked,  the  child 
evidently  suffering  from  a  laryngitis  ;  this  is  followed  by  an  indefinite 
mottling  about  the  neck  and  hands  as  the  laryngeal  symptoms  abate. 

Severe  and  Complicated  iVTeasles. — Epidemics  of  measles  differ  greatly 
in  the  severity  of  the  individual  attacks.  Most  of  these  fatal  attacks  are 
characterised  by  high  fever,  dry  brown  tongue,  delirium,  and  convulsions  due 
to  an  intense  hypersemia  of  the  internal  organs,  more  especially  the  lungs 
and  brain.  The  heart's  action  is  depressed,  the  rash  ill-defined,  the  skin 
dusky,  and  in  some  cases,  markedly  petechial.  In  such  cases  death  may  take 
place  on  the  third  or  fourth  day,  or  improvement  may  commence  at  the  end 
of  a  week.  In  the  majority  of  cases  measles  threatens  life  through  the 
tendency  to  inflammation  of  the  lungrs.  The  lung  symptoms  may  be  pro- 
minent from  the  first,  or  the  presence  of  pneumonia  may  delay  convalescence 
or  supervene  when  the  acute  symptoms  have  passed  away.  In  the  former 
case  the  symptoms  are  those  of  acute  broncho-pneumonia,  the  temperature 
continues  high,  perhaps  105°  or  106°,  there  is  marked  dyspnoea,  sibilant  sounds 
are  heard  over  the  whole  chest,  the  air  does  not  enter  the  bases  freely  ;  the 
rash  is  scanty,  perhaps  only  an  ill-defined  mottling  ;  delirium  followed  by 
coma  comes  on  ;  the  eyelids  become  glued  together  with  thick  semi-purulent 
secretion,  sordes  appear  on  the  mouth,  the  tongue  is  brown  and  dry,  and 
unless  improvement  takes  place  the  child  sinks. 

Catarrhal  or  IVIem'branous  Iiaryng-itis  is  not  uncommon  in  the  pre- 
emptive stage,  or  as  the  eruption  is  receding.  Tracheotomy  may  be  required 
if  the  obstruction  to  respiration  becomes  sufficient  to  threaten  life,  but  it 
must  be  borne  in  mind  that  an  amelioration  of  symptoms  generally  takes 


Measles  271 

place  when  the  rash  appears.  In  those  cases  attended  with  membranous 
exudation  the  laryngitis  generally  follows  rather  than  precedes  the  eruption. 
Ophthalmia  frequently  occurs  in  anaemic  and  unhcalth)'  children  :  f:orncitis 
and  corneal  ulcers  may  also  be  met  with.  Glandular  enlarg^ements 
may  develop,  the  deep  cervical  gland  being  especially  involved,  as  in  scarlet 
fever  ;  abscesses  are  not  common.  Otitis  is  very  common  during  con- 
valescence, suppuration  taking  place  in  the  middle  ear  and  the  membrane 
becoming  perforated.  Dlarrhcea  is  not  an  uncommon  complication  or 
sequela,  especially  during  the  hot  weather,  though  by  no  means  e.xclusively 
so  :  it  is  apt  to  become  dysenteric  in  character,  mucus,  blood,  and  hard  lumpy 
faeces  being  passed,  with  prolapse  of  the  bowel. 

The  health  often  remains  impaired  for  a  considerable  time  after  an  attack 
of  measles  ;  it  is  during  this  stage  that  Acute  Tuberculosis  and  Cancrum 
oris  may  arise.  The  tuberculosis  very  frequently  appears  to  take  its  rise 
from  enlarged  and  cheesy  bronchial  glands. 

Diagnosis. — The  disease  most  likely  to  be  mistaken  for  measles  is  rubella, 
the  latter  disease  closely  resembling  mild  measles.  (^See  Rubella.)  A 
measly  rash  is  sometimes  present  in  cases  of  septicsemia,  where  there  is 
suppuration  as  in  empyema. 

It  is  possible  to  confound  measles  with  smallpox,  though  this  difficulty  is 
more  likely  to  arise  in  the  case  of  adults  than  children.  According  to  Collie 
there  are  two  kinds  of  smallpox  which  it  is  possible  to  confound  with  measles, 
\  iz.  the  commencement  of  a  confluent  case  and  the  commencement  of  a  haemor- 
rhagic  case.  The  papules  in  smallpox  are  much  harder  and  more  shotty, 
and,  moreover,  in  a  confluent  case,  the  headache,  lumbar  pain,  and  general 
symptoms  would  be  more  severe.  Heemorrhagic  measles  is  very  rare,  and, 
according  to  the  same  author,  would  be  difficult  to  diagnose  from  '  black 
smallpox;'  the  quantity  and  quality  of  the  vaccination  marks  should  be 
taken  into  account. 

Morbid  Aiiatomy. — There  is  not  much  to  be  said  under  this  head,  inas- 
much as  there  are  no  post-nio7'tem  appearances  characteristic  of  measles, 
the  principal  lesion  found  being  catarrhal  pneumonia  ;  the  whole  of  the 
internal  organs  are  gorged  with  blood,  and  minute  haemorrhages  are  present 
on  their  surfaces.  The  mucous  membrane  of  the  bronchi  is  intensely  con- 
gested, the  surface  of  the  pleura  roughened  and  perhaps  covered  with  lymph, 
one  or  both  bases  being  sohd  from  catarrhal  pneumonia  ;  in  such  case  the 
pneumonia  resembles  that  found  in  septicjemia.  In  some  instances  croupous 
pneumonia  involving  a  lobe  or  portion  of  a  lobe  may  be  present,  or  there 
may  be  patches  of  croupous  pneumonia.  At  other  times  there  is  intense 
bronchitis,  with  patches  of  catarrhal  pneumonia  and  emphysema.  In  all 
cases  of  pneumonia  following  measles  which  we  have  examined  micro- 
scopically we  have  found  fibrinous  exudation  in  the  air  vesicles,  in  spite  of 
the  pneumonia  being  apparently  of  the  catarrhal  variety.  Aflbrinous  exuda- 
tion is  sometimes  found  on  the  mucous  membrane  of  the   arge  bowel. 

The  follo\\'ing  post-inortem  record  taken  from  one  of  our  note  books 
illustrates  a  malignant  case  : — 

Measles,  maligna?it  case;  death. — Child  of  eleven  months;  death  on  fourth  day. 
On  removing  lungs  it  is  noted  that  the  upper  lobes  are  emphysematous  on  their  surfaces  ; 
in   the   lower   lobes   emphysema   alternates   with    collapse ;    on  section   there   is   intense 


2/2  TJie  Specific  Fevers 

injection  of  the  trachea  and  bronchi,  yellow  mucus  exudes  from  the  minute  bronchi ; 
the  lungs  are  intensely  congested,  there  are  patches  of  broncho-pneumonia  in  the  lower 
lobes. 

Treatment. — No  very  active  treatment  is  needed  during  an  attack  of 
ordinary  severity,  but  much  may  be  done  to  promote  the  patient's  comfort  and 
to  prevent  any  compHcations.  He  should,  of  course,  be  confined  to  bed  as 
soon  as  measles  is  suspected,  the  temperature  of  the  room  being  maintained 
at  65°  F.,  and  if  the  cough  is  hard  and  irritating  a  steam  kettle  should  be 
called  into  requisition  to  keep  the  atmosphere  moist.  The  diet  should  con- 
sist of  milk  diluted  with  barley  water  or  seltzer  ;  in  mild  cases  sops  or  light 
puddings  may  be  allowed.  Demulcent  drinks,  such  as  barley  water,  lemonade, 
black  currant  or  tamarind  drinks  or  jellies,  are  useful  in  allaying  the  irritating 
cough.  Frequent  spongings  with  warm  water  containing  a  weak  solution 
of  tar  or  '  sanitas '  relieve  the  itching  and  help  to  bring  out  the  rash.  During 
the  pre  eruptive  stage,  when  there  are  high  fever,  restlessness,  cough,  and 
frequent  pulse,  small  doses  of  tr.  aconiti,  one  or  two  drops  every  two  hours 
—  carefully  watching  the  effect,  especially  after  five  or  six  doses  have  been 
given — will  be  usually  attended  with  relief.  Jelly  c&ntaining  codeia  or  small 
doses  of  Dover's  powder  may  be  given  to  relieve  the  cough.  Great  cai'e 
should  be  exercised  during  convalescence  to  prevent  catching  cold,  especially 
in  those  who  are  liable  to  bronchial  catarrh,  as  the  bronchial  mucous  mem- 
brane remains  for  some  time  in  an  irritable  condition,  and  exposure  to  cold 
is  exceedingly  likely  to  give  rise  to  bronchitis  or. diarrhoea. 

In  cases  of  greater  severity,  especially  those  in  small  children  which  are 
accompanied  by  a  scanty  rash,  congestion  of  the  internal  organs,  high  tem- 
perature, and  broncho-pneumonia,  active  treatment  is  required.  It  is  neces- 
sary to  get  the  skin  to  act  efficiently  and  thus  relieve  the  congested  internal 
organs  ;  to  this  end  tepid  sponging,  hot  packs,  or  mustard  baths  may  be 
employed.  For  children  under  two  years  of  age  the  mustard  bath  is  the 
most  suitable  ;  the  child  being  placed  for  three  minutes  in  a  bath  of  100°  F., 
one  table-spoonful  of  mustard  to  the  gallon  of  water  being  about  the  proper 
strength.  The  child  must  be  quickly  dried  and  put  between  blankets  ;  the 
bath  may  be  repeated  in  a  couple  of  hours  if  necessary.  The  stimulating 
effect  of  the  bath  upon  the  skin  is  often  of  great  service.  Linseed  poultices 
to  the  chest  are  to  be  avoided  in  the  case  of  young  children,  unless  the 
attendants  are  trained  nurses  ;  hot  fomentations  or  bran  poultices  are  pre- 
ferable in  dispensary  practice  and  in  the  hands  of  the  unskilled,  as  being  less 
heavy. 

In  older  children  the  hot  pack  is  to  be  preferred  to  baths.  In  the  early 
stages  small  doses  of  antimony,  pot.  ant.  tart.  t^^tt-jV  of  ^  grain,  with  some 
tartarated  soda  or  citrate  of  ammonia,  should  be  given  every  three  or  four 
hours,  but  omitted  if  there  is  nausea.  Aconite  may  be  useful,  but  it  must  be 
carefully  watched,  on  account  of  the  depression  it  is  apt  to  produce  if 
pushed  too  far.  Alcohol  in  the  form  of  whisky  or  brandy  should  be  given  if 
the  pulse  is  small  and  rapid  and  the  tongue  dry  and  brown.  If  the  cough 
becomes  loose  and  there  is  excessive  secretion  from  the  bronchi,  ammonia, 
digitalis,  and  alcohol  in  combination  should  be  given.  The  eyes,  nose, 
and  mouth  in  severe  cases  require  attention  ;  they  should  be  bathed  or 
mopped  out  with  warm  water  ;  if  there  are  any  aphthous  patches  in  the 


Measles — R  n  bell  a  273 

mouth  some  borax  in  dilute  glycerine  should  be  applied.  Otitis  and  glan- 
dular inflammation  may  require  attention.  During  convalescence  no  medicine 
answers  better  than  nitric  acid  and  bark.     (F.  48,  49). 

(2ua7-antine. — How  long  should  quarantine  be  maintained  in  a  case  of 
measles  ?  This  is  not  an  easy  question  to  answer,  though  it  is  certain  that 
the  infection  is  not  given  off  from  the  patient  for  so  long  a  period  as  is  the 
casein  scarlet  fever.  In  uncomplicated  cases  hot  baths  may  be  given  as  the 
rash  begins  to  disappear  ;  they  are  useful  to  cleanse  the  skin  and  render 
the  patient  more  comfortable.  It  is  well  for  the  patient  to  keep  his  bed  for  ten 
days  and  his  room  for  three  weeks  ;  then,  if  he  is  quite  well  in  every  respect, 
there  can  be  little  danger  in  his  mixing  with  his  fellows.  When  a  case  of 
measles  occurs  in  a  house,  it  is  necessary  for  the  other  children  who  have 
not  had  it  to  stop  going  to  school  or  mixing  with  other  children,  as  it  is 
probable  they  will  have  contracted  the  disease  ;  and  as  measles  is  infec- 
tious in  its  early  stages — if  not  during  the  incubation  period — they  may 
readily  be  the  means  of  giving  it  to  others.  For  the  same  reason  it  is  un- 
wise to  send  them  away  from  home,  though  care  should  be  taken  that  they 
do  not  come  in  contact  with  the  patient  at  home.  The  bedding  should  be 
stoved  and  the  room  occupied  by  the  patient  disinfected  at  the  conclusion  of 
the  illness. 

Rubella 

Rubella'  is  an  infectious  fever  closely  resembling  but  distinct  from 
measles  ;  it  is  for  the  most  part  a  milder  disorder  than  measles,  and  does  not 
protect  from  it.     In  some  epidemics  it  closely  resembles  mild  scarlet  fever. 

Etiology. — The  resemblance  between  these  two  diseases  is  unquestion- 
ably a  close  one,  and  there  is  little  doubt  that  not  infrequently  epidemics  of 
rubella — or  at  any  rate  sporadic  cases — are  mistaken  for  measles.  It  has, 
however,  been  clearly  shown  by  those  who  have  had  the  opportunity  of 
watching  successive  epidemics  of  infectious  diseases  in  schools  and  asylums, 
where  the  same  individuals  have  been  attacked,  that  rubella  does  not 
protect  from  either  measles  or  scarlet  fever,  nor  do  attacks  of  the  two  latter 
afford  any  immunity  from  attacks  of  rubella.  The  resemblance,  and  yet  the 
difference,  between  the  two  diseases  was  well  put  by  the  late  Dr.  West  when 
he  said  'they  resemble  each  other  somewhat  as  varicella  and  variola — alike, 
but  not  the  same — not  twin  sisters  indeed,  but  half-sisters  at  any  rate.' 
That  they  should  be  confounded  in  practice  is  not  surprising,  especially 
when  we  remember  that  measles  is  sometimes  an  extremely  slight  disease 
and  the  rash  by  no  means  characteristic.  In  mild  attacks  of  measles  the 
coryza  is  usually  slight  or  absent,  and  the  rash  little  else  than  ill-defined 
mottling. 

Rubella  occurs  in  epidemics,  sometimes  being  prevalent  and  widespread, 
as  it  was  in  this  country  during  1880  ;  at  other  times  sporadic  cases  crop  up 
and  there  appears  but  little  tendency  for  the  disease  to  spread.  As  a  result, 
rubella  has  earned  a  different  character  as  regards  contagiousness  from 
different  writers  who  have  observed  it,  some  maintaining  that  its  contagious- 
ness is  almost  m7,  and  others  that  it  is  extremely  contagious.     The  truth  is 

'  We  adopt  the  term  rubella  as  first  suggested,  we  believe,  by  W.  Squire.  '  Epidemic 
roseola,'  which  has  been  proposed,  introduces  the  ambiguous  term  of  '  roseola.' 

T 


274  The  Specific  Fevers 

that  susceptibility  to  its  influence  seems  to  vary  strangely  at  different  times 
and  in  different  places  in  a  way  which  it  is  difficult  to  account  for.  Thus  in 
one  locality  there  may  be  an  epidemic  prevalent  ;  an  individual  goes  to 
another  while  incubating,  he  suffers  from  an  ordinary  attack  and  the  disease 
does  not  spread,  though  he  comes  in  contact  with  many  individuals.  There 
is  little  doubt,  however,  that  rubella  has  been  confounded  with  some  of  the 
non-specific,  non-contagious  forms  of  roseola  or  rose  rash.  Age  does  not 
seem  greatly  to  influence  predisposition  ;  infants,  children,  and  adults  suffer- 
ing alike  ;  indeed,  in  some  epidemics  adults  suffer  more  in  proportion  to 
their  numbers.  Thus  in  an  epidemic  in  the  Children's  Hospital  observed 
by  Dr.  Hutton  and  ourselves,  out  of  twenty-seven  cases,  eight  were  those  of 
lady  probationers  or  '  sisters,'  and  nineteen  of  children  ;  so  that  the  adults 
suffered  far  more  largely  in  proportion  to  their  numbers,  though  there  can 
be  no  doubt  that  the  nurses  came  in  contact  with  those  suffering  from  the 
disease  much  more  than  the  children.  Considering  how  much  rarer  a  dis- 
ease rubella  is  than  measles,  it  would  appear  that  a  smaller  number  of 
individuals  who  are  unprotected  by  a  previous  attack  are  susceptible  to  its 
influence. 

The  relationship  of  rubella  to  measles  and  scarlet  fever  is  an  interesting- 
question,  and  while  very  few  believe  it  to  be  a  hybrid  disease,  the  attack 
resulting  from  the  reception  by  the  patient  of  both  scarlatinal  and  measles 
poisons,  yet,  considering  the  close  resemblance  which  it  bears  to  measles, 
there  is  nothing  inherently  improbable  in  the  idea  that  the  resemblance  is 
something  more  than  coincidental,  that  the  poisons  may  have  been  derived 
from  one  another  or  from  the  same  stock  at  some  distant  epoch,  and  have 
become  modified  by  being  cultivated  under  different  conditions.  It  is  inter- 
esting to  note  that  some  observers  assert  that  the  character  of  an  epidemic 
becomes  modified  in  the  direction  of  either  measles  or  scarlet  fever  if  either 
of  these  is  prevailing  at  the  same  time. 

It  is  a  curious  fact  that  there  are  epidemics  of  rubella,  in  which  the  rash 
closely  resembles  scarlet  fever  and  not  measles,  as  is  generally  the  case. 
Whether  the  two  forms  are  distinct  diseases  or  only  varieties  of  the  same 
disease,  it  is  impossible  to  say.  We  cannot  say  whether  the  measles  variety 
protects  from  the  scarlatinal  variety. 

Incubation. — There  has  been  some  uncertainty  about  the  length  of  the 
incubation  period.  The  common  period  is  from  two  to  three  weeks,  as  observed 
both  by  W.  Squire  and  Lewis  Smith.  In  three  cases  coming  under  our  own 
observation  the  time  appeared  to  be  sixteen,  seventeen,  and  eighteen  days 
respectively. 

Premonitory  Stage. — In  children,  as  a  rule,  no  prodromal  symptoms  are 
observed,  the  rash  being  the  first  thing  to  be  noticed.  In  adults  who  are 
able  to  describe  their  feelings,  complaint  is  madeof  weariness,  headache,  and 
backache  for  twenty-four  hours  before  the  appearance  of  the  rash.  There 
may  be  vomiting,  coryza,  slight  sore-throat,  or  a  tingling  sensation  of  the 
skin  of  the  face.  Another  noteworthy'  symptom  sometimes  present  is  the 
enlargement  of  the  superficial  lymphatic  glands  situated  along  the  posterior 
edge  of  the  sterno-mastoid,  or  the  submaxillary  and  occipital  glands  are 
tender  as  well  as  slightly  enlarged,  and  give  rise  to  a  certain  amount  of 
stiffness  of  the  neck.     On  the  other  hand,  it  is  by  no  means  uncommon  even 


Rubella  275 

in  adults  that  the  disco\ery  of  a  rash  is  the  first  thing  to  call  attention  to  the 
attack. 

Prodromal  Stage,  measles  variety. — The  rash  usually  appears  first  on 
the  face,  and  consists  of  indistinct,  ill-defined  papules,  forming  irregular 
patches  of  a  rose-red  colour,  which  shade  away  into  the  colour  of  the  skin  ; 
there  may  be  simply  erythematous  blotches.  The  patches  of  confluent 
papules  vary  much  in  size  and  shape,  many  perhaps  consisting  of  only  a  few 
papules  grouped  together  ;  sometimes,  on  the  contrary,  the  whole  face  is  of 
a  red  colour.  The  rash  is  usually  also  abundant  on  the  neck,  chest,  back, 
buttocks,  and  flexor  sui-faces  of  the  arms  and  thighs  ;  in  these  situations  it 
is  usually  less  confluent  and  patchy  than  on  the  face,  the  rash  consisting  of 
groups  of  papules  or  of  single  papules.  Occasionally  the  confluence  of  the 
papules  and  the  erythema  which  surrounds  them  give  rise  to  the  suspicion  ol 
scarlet  fever,  especially  to  that  form  in  which  the  rash  is  patchy  on  the  limbs, 
but  the  rash  of  rubella  always  consists  of  papules,  and  is  not  diffuse  or  punc- 
tated as  is  the  rash  of  scarlet  fever.  Rubella  rashes  undoubtedly  vary  con- 
siderably, especially  in  the  confluence  of  the  papules  ;  as  a  rule,  the  colour 
is  of  a  rose-red  when  it  first  comes  out,  being  of  a  brighter  colour  than 
measles  ;  the  papules  do  not  so  constantly  arrange  themselves  in  crescents, 
and  they  are  less  distinct  than  the  measles  papules.  The  rash  is  usually  most 
intense  on  the  second  day,  but  remains  visible  for  three  or  four  days ;  by 
the  end  of  this  time  it  has  mostly  faded,  often  leaving  more  or  less  staining 
of  the  skin  and  a  light  branny  desquamation.  The  rash  frequently  gives 
rise  to  much  itching.  Sometimes  the  axillary  and  inguinal  glands  become 
enlarged. 

The  course  of  the  attack  may  be  feverless,  though  usually  there  is  a  slight 
rise  of  temperature,  the  highest  being  on  the  second  day,  99°  to  100°  ;  in  rare 
cases  it  reaches  102°  or  103°.  The  temperature  becomes  normal  as  the  rash 
disappears. 

Hypera^mia  of  the  conjunctiva  and  fauces  exists  in  many  cases,  but  it  is 
rarely  as  marked  a  feature  of  the  attack  as  it  is  in  measles.  Sometimes  a 
dryness  and  soreness  of  the  throat  in  swallowing  is  complained  of,  with  more 
or  less  catarrhal  tonsillitis. 

While  such  may  be  taken  as  a  typical  attack,  it  must  be  acknowledged 
that  the  attacks  of  this  exanthem  vary  greatly  in  intensity,  and  the  rash  may 
be  too  ill  defined  to  admit  of  a  positive  diagnosis.  In  some  rare  cases,  such 
as  those  described  by  Dr.  Cheadle,  the  course  of  the  disease  is  that  of  a  serious 
illness,  with  marked  implication  of  the  larynx  and  bronchi,  the  cough  being 
incessant  and  crouplike.  In  two  of  these  broncho-pneumonia  supervened,  in 
several  others  earache  was  a  prominent  symptom.  On  the  other  hand,  cases 
may  occur  of  the  mildest  form,  so  wanting  in  character  both  as  regards  rash 
and  coryza,  that  they  may  be  looked  upon  as  of  a  doubtful  nature  and  perhaps 
forgotten,  and  only  when  they  are  succeeded  by  more  typical  cases  does 
their  character  become  clear. 

Scarlatinal  variety. — Some  years  ago  we  were  much  puzzled  by  finding 
that  a  number  of  what  were  apparently  mild  cases  of  scarlet  fever,  when 
admitted  to  our  fever  ward  developed  scarlet  fever  a  few  days  after  their 
admission.  Shortly  after  we  noted  a  number  of  patients  coming  to  the  out- 
patient department  with  diffuse  red  rashes,  but  who  were  hardly  ill  at  all, 


2/6  TJie  Specific  Fevers 

but  had  been  brought  on  account  of  the  rash.  It  soon  became  apparent 
that  there  was  an  epidemic  of  a  disease  closely  resembling  scarlet  fever  yet 
distinct  from  it,  inasmuch  as  it  left  the  patient  still  susceptible  to  an  attack 
of  scarlet  fever.  This  epidemic  was  no  doubt  one  of  the  scarlatinal  variety 
of  rubella.  In  many  of  the  cases  there  was  a  history  of  vomiting  as  an 
initial  symptom,  complaint  of  sore  throat,  slight  fever,  and  a  very  well-marked 
rash,  while  the  child  hardly  felt  ill  at  all.  The  rash  was  usually  copious, 
and  could  not  be  distinguished  from  scarlet-fever  rashes,  but  was  more  of  a 
rose  tint,  and  less  distinctly  punctiform  in  character — that  is,  there  was  a 
uniform  redness  without  the  red  points  which  correspond  with  the  hair 
follicles  being  well  marked.  Still,  we  must  admit  that  the  rash  seen  in 
these  cases  was  indistinguishable  from  some  undoubted  scarlet-fever  rashes. 
When  once  such  an  epidemic  is  known  to  prevail  the  diagnosis  ceases  to  be 
difficult.  The  fever,  malaise,  and  sore  throat  are  slight,  while  the  rash  is  copi- 
ous. In  scarlet  fever  with  a  copious  rash  the  fever  is  usually  high,  the  tonsils 
are  angry  and  swollen,  and  the  child  is  evidently  ill.  Mild  cases  would  not 
be  likely  to  occur  one  after  another ;  some  would  be  certain  to  be  sharp  and 
typical.  Desquamation  follows  the  red  rash  of  rubella,  but  it  is  rarely  as  well 
jnarked  as  in  typical  cases  of  scarlet  fever,  where  the  rash  has  been  copious 
and  the  fever  sharp.  Some  authors  lay  great  stress  on  the  enlargement  of 
the  lymphatic  glands  behind  the  sterno-mastoid,  axilla,  and  inguinal  region. 
This  is  no  doubt  true,  but  they  are  not  universally  enlarged  ;  we  have 
certainly  seen  cases  of  both  varieties  of  rubella  without  any  lymphatic 
enlargement.  In  some  cases  and  in  some  epidemics  the  rash  is  more 
patchy  than  the  rash  described,  but  we  have  not  seen  many  such.  It  must 
be  borne  in  mind  that  the  scarlatinal  variety  of  rubella  is  a  comparatively 
rare  disease,  while  scarlet  fever  is  a  very  common  one,  and  that  an  isolated 
case  of  fever  with  sore  throat  and  a  diffuse  red  rash  is  far  more  likely  to  be 
scarlet  fever  than  rubella,  however  mild  and  uncomplicated  it  may  prove  to 
be.  To  find  that  a  child  we  have  declared  to  be  suffering  from  '  German 
measles '  has  acute  nephritis,  is,  to  say  the  least  of  it,  an  unpleasant  dis- 
covery. 

Rose  rashes,  diffuse  and  patchy,  may  make  their  appearance  after  the 
ingestion  of  some  improper  food,  or  in  hot  summer  weather.  There  is  usually 
an  absence  of  both  sore  throat  and  fever.  The  possibility  of  a  red  rash 
being  due  to  belladonna  must  not  be  forgotten. 

Coiiiplicatio7is  mid  SeqitelcE. — There  are  usually  none  ;  in  the  more  severe 
cases  catarrhal  disorders,  such  as  coryza,  tonsihitis,  and  broncho-pneumonia 
may  complicate  and  succeed  the  attack.  The  prognosis  is  favourable  ;  the 
disease  is  probably  never  fatal  in  healthy  children  ;  in  epidemics  in  hospitals, 
where  it  attacks  children  already  suffering  from  and  much  reduced  by 
pulmonary  affections,  it  has  appeared  to  be  the  immediate  cause  of  a  fatal 
result.  Even  in  healthy  children  the  health  may  remain  below  par  for 
some  time  afterwards. 

Diagnosis.—  Rubella  may  at  times  be  mistaken  for  some  of  the  anomalous 
erythematous  or  roseolous  rashes  from  which  children  suffer  from  various 
causes,  especially  indigestible  food  ;  but  there  is  usually  no  fever.  In  single 
cases  diagnosis  may  be  difficult,  but  the  fact  that  rubella  prevails  in  epidemics 
often  assists  in  making  a  diagnosis.     The  diagnosis  between  measles  and 


Rubella 


277 


rubella  in  an  individual  case  is  at  times  impossible  ;  often  it  is  difficult, 
inasmuch  as  it  must  be  admitted  that  there  is  no  one  characteristic  symptom 
of  rubella,  and  moreover  the  rash  differs  in  different  cases.  The  differences 
between  typical  cases  of  rubella,  measles,  and  scarlet  fe\"er  are  shown  in 
the  table  below. 

Treat))ieiit. — ^Every  case  of  rubella  and  every  suspicious  case  should  be 
carefully  isolated,  and  confined  to  one  room,  if  not  to  bed.  The  diet  should 
consist  largely  of  fluids  and  slops.  A  simple  saline  such  as  citrate  of  potash 
may  be  given,  and  other  symptoms  must  be  treated  as  they  arise. 

Quarantine. — The  patient  should  be  isolated  for  at  least  three  weeks  ; 
better  if  four  weeks  elapse  before  he  is  allowed  to  rejoin  his  companions 


— 

Rubella 

Measles 

Scarlet  Fever 

Incubation. 

14  to  21  days. 

8  to  12  days. 

2  to  5  days. 

Premonitory  fev. 

I  day. 

3  to  4  days. 

I  day. 

Prodromal  sym- 

Often none.  Sometimes 

Sneezing,       coryza, 

Vomiting,  headache, 

ptoms. 

enlarged        glands, 
weariness  and  slight 
corj'za. 

headache,  cough. 

sore  throat. 

Tonsillitis. 

Slight  tonsillitis. 

Usually  none. 

Tonsillitis  well 
marked. 

Rash. 

Appears  on  the  first  or 

Appears      on      the 

A  diffuse  punctiform 

second   day.      Con- 

fourth or  fifth  day. 

red     rash    comes 

sists     of    indistinct 

Consists  of  conflu- 

over neck,  trunk. 

papules  of  a  rose-red 

ent  papules   of  a 

and     limbs — may 

colour  confluent  on 

dusky  red   colour 

be  patches  on  the 

the  face,  usually  dis- 

on  the  face,   and 

extremities. 

crete   on  the  limbs, 

groups  of  papules 

buttocks,  and  thighs. 

often  in  a  crescen- 

Often  fades  from  the 

tic    form    on    the 

face  before  it  is  fully 

trunk  and  limbs. 

developed  elsewhere. 

Often  much  itching. 

In  the  scarlatinal  va- 

riety the  rash  closely 

resembles       scarlet 

fever.      It    is    rose- 

red,      diffuse,     less 

markedly       puncti- 

form    than     typical 

scarlet  fever. 

Desquamation. 

Desquamation   absent 

Desquamation     ab- 

Desquamation  usu- 

or    only    very    fine 

sent  or  only  in  fine 

ally  free. 

branny  scales. 

scales. 

Temperatm'e. 

Often  normal  through- 

Fever   always    pre- 

Fever   always    pre- 

out,    rarely     above 

sent,      sometimes 

sent,  mostly  high, 

100^  F. 

high,    reaches    its 

disappears  as  the 

maximum      when 

rash  fades. 

the  rash    is  fully 

out,  then  falls. 

2/8  The  Specific  Fevers 


CHAPTER   XV 

THE   SPECIFIC    FEVERS — {C07ltimied) 

Diphtheria 

Diphtheria  is  an  infectious  disorder  which  is  characterised  by  the  for- 
mation of  a  fibrinous  exudation  on  mucous  surfaces  or  abi'aded  skin,  due  to 
the  growth  of  a  specific  bacilkis  ;  it  is  usually  accompanied  by  anaemia  and 
albuminuria,  and  frequently  followed  by  paresis  of  various  muscles.  At  the 
very  threshold  of  the  subject  it  maybe  as  well  to  attempt  to  clear  the  ground 
by  asking — Are  we  to  consider  all  fibrinous  exudations  which  have  the 
characters  of  a  '  false  membrane '  as  evidence  of  the  presence  of  diphtheria  ? 
Is  diphtheria  always  accompanied  by  a  'false  membrane'?  Both  these 
questions  must  be  answered  in  the  negative.  Recent  observations  clearly 
show  that  other  micro-organisms  besides  the  D-bacillus  are  capable  of  pro- 
ducing fibrinous  exudations  on  the  fauces,  and,  moreover,  the  D-bacillus  has 
been  demonstrated  in  the  secretions  taken  from  non-membranous  sore 
throats.  Still,  we  must  admit  that  membranous  exudations  are  usually 
diphtheritic,  and  that  diphtheria  is  not  often  present  in  the  absence  of 
'  false  membrane.' 

That  diphtheria  is  a  highly  contagious  disorder  is  made  certain  by  very 
definite  evidence  ;  it  is  a  matter  of  common  experience  that  the  disease 
passes  from  patient  to  nurse,  from  one  patient  to  another  in  the  wards  of  a 
hospital,  and  from  a  sick  child  to  its  playmates  or  parents  in  private  houses. 
It  is  certain  also  that  the  infection  can  be  conveyed  from  the  sick  to  the 
healthy  by  means  of  a  third  person,  the  infected  particles  travelling  on  the 
clothes  or  on  the  hands  of  the  latter.  The  occurrence  of  diphtheria  in  the 
families  of  medical  men  who  were  attending  cases  of  diphtheria  is  a  proof  of 
this.  Direct  inoculation  has  taken  place  accidentally  by  means  of  small 
pieces  of  membrane  or  the  secretions  entering  the  mouth,  as  in  sucking  a 
tracheotomy  wound  ;  false  membrane  has  formed  within  twenty-four  hours 
of  an  operation  at  the  seat  of  the  wound.  The  disease  is  often  spread  in 
schools  and  families  by  individuals  who  are  not  ill  enough  to  be  laid  up, 
going  about  while  suffering  from  mild  and  unrecognised  diphtheria.  There 
is  little  doubt  also  that  the  disease  has  been  transferred  from  animals  to 
man  through  direct  contact  or  by  means  of  milk  from  cows  suffering  from 
the  disease.  The  D-bacillus  may  retain  its  vitality  for  many  months  out- 
side the  bod)^,  and  may  be  carried  any  distance  in  clothes,  bed  linen,  or  on 
surgical  instruments.  It  is  possible,  though  we  believe  unproven,  that  the 
D-bacillus  may  grow  and  develop  in  sewage,  in  cesspools,  and  drains,  and 


Diphtheria  279 

re-enter  the  l^ocly  l^y  the  inhalation  of  sewer  gas.  It  is  a  popular  notion 
that  there  is  a  close  connection  between  diphtheria  and  sewer  gas,  and 
sanitary  faults  in  houses  are  frequently  credited  with  being  the  cause  of 
outbreaks  of  diphtheria  ;  and  it  is  quite  possible  that  sewer  gas  may  give 
rise  to  a  non-specific  sore  throat  which  may  form  a  suitable  soil  for  the  de- 
velopment of  the  D-bacillus. 

Diphtheria  occurs  in  epidemics,  but  it  is  also  endemic  in  some  cities  and 
rural  districts.  It  is  constantly  present  in  such  cities  as  Berlin,  Paris,  and 
New  York,  and  in  some  rural  districts  in  this  country.  In  its  distribution 
and  in  the  varying  character  of  its  epidemics  it  is  one  of  the  most  mysterious 
diseases  with  which  we  are  acquainted,  and  there  is  much  about  it  which 
requires  continued  investigation.  In  this  country  until  recently  it  has  been 
more  common  in  the  rural  than  in  the  urban  districts,  though  it  appears  at 
the  present  time  to  be  more  common  now  in  our  large  towns  than  formerly. 
It  is  especially  prevalent  in  the  south-eastern  and  eastern  rural  districts, 
while  some  others  appear  to  escape  almost  entirely.  It  makes  its  appear- 
ance at  times  in  isolated  farmhouses,  or  villages  remote  from  other  habi- 
tations, and  this  circumstance  has  suggested  the  idea  that  possibly  the 
infective  particles  have  been  conveyed  thither  by  means  of  the  wind  (Airy). 
It  has  occurred  in  Central  Africa  far  away  from  any  source  of  infection. 
But  in  connection  with  these  singular  cases  we  must  remember  that  the 
D-bacillus  retains  its  vitality  for  many  months  under  suitable  conditions, 
and  may  be  conveyed  any  distance  on  clothes  or  other  articles,  and  thus 
infect  persons  long  distances  away  from  the  original  source  of  the  infection. 

No  age  is  exempt  from  its  attacks,  but  children  between  the  ages  of  two 
and  eight  years  are  most  often  attacked,  and  children  of  these  ages  more 
readily  succumb  than  do  older  children.  The  disposition  to  diphtheria 
seems  to  run  in  families,  members  of  the  same  family  being  attacked  in 
quick  succession  or  at  variable  intervals. 

The  parts  which  are  most  often  attacked  are  the  fauces,  nasal  mucous 
membrane,  larynx  and  trachea,  glans  penis  and  vulva  ;  less  often  some  wound 
or  eczematous  skin.  The  bacillus  enters  the  mouth  in  either  air  or  food, 
and  if  conditions  are  favourable  for  its  development  the  growth  of  the 
bacillus  commences,  and  membrane  forms  on  the  tonsils  and  soft  palate. 
In  what  these  favourable  conditions  consist  it  is  difficult  to  say.  Cer- 
tainly a  slight  sore  throat  or  laryngeal  catarrh  often  precedes  an  attack 
of  diphtheria,  and  it  is  very  probable  that  any  injury  to  the  epithelium  or  a 
catarrhal  state  may  afford  a  suitable  soil  for  the  development  of  the  bacillus. 
We  ha\'e  known  instances  in  which  nasal  diphtheria  has  supervened  in  a 
case  of  chronic  ozeena,  wdiile  other  children  exposed  to  infection  at  the 
same  time  were  not  attacked.  The  fatality  of  different  epidemics  varies 
strangely  ;  sometimes  whole  families  are  swept  away,  as  in  the  epidemic 
described  by  Trousseau  in  Sologne,  where  in  one  farm,  where  the  residents 
numbered  eighteen,  only  two,  the  father  and  a  servant  girl,  survived.  The 
infection  seems  to  vary  in  intensity,  at  times  and  under  certain  conditions 
becoming  attenuated,  at  other  times  resuming  its  virulency. 

Morbid  Anatomy  a?td  Pathology. — The  membranous  exudation  which  is 
present  in  diphtheria  is  of  a  whitish-grey  colour,  and  when  first  formed  is 
firmly  adherent  to  the  tissues  beneath  it.    It  is  in  some  cases  rather  yellowish 


28o  The  Specific  Fevers 

than  white  ;  in  mahgnant  cases  it  is  frequently  brown  from  being  stained 
by  broken-down  blood.  In  a  few  days  more  or  less  the  membrane  becomes 
loosened  from  its  attachment  and  can  be  removed  by  means  of  a  brush  ;  if 
forcibly  removed  it  leaves  a  raw  surface,  which  quickly  becomes  again 
covered  with  membrane.  Speaking  generally,  membrane  adheres  more 
firmly  and  is  less  easily  detached  from  the  mucous  membrane  of  the  tonsils 
and  soft  palate  than  from  the  larynx  and  trachea.  If  a  thin  section  of  a 
piece  of  membrane  adhering  to  the  soft  palate  be  stained  with  methyl 
blue,  and  examined  with  a  moderately  high  power,  it  will  be  seen  that  the 
membrane  consists  of  a  fine  network  of  fibrin  with  epithelial  cells  and 
leucocytes  in  the  meshes  ;  beneath  the  membrane  the  papillse  and  connective 
tissue  of  the  deeper  layers  of  the  mucous  membrane  will  be  seen  to  be  in- 
filtrated with  leucocytes.  Loeffier's  D -bacilli  are  to  be  seen,  usually  in  little 
balls  or  masses  embedded  in  the  superficial  layers  of  the  false  membrane  ; 
in  some  cases  they  may  be  seen  in  the  deeper  part  of  the  membrane  or 
beneath  it.  Unlike  the  anthrax  bacillus,  the  D-bacillus  remains  local, 
and  does  not  penetrate  into  the  tissues  or  enter  the  blood.  The  D-bacillus 
is  a  non-motile  little  rod  about  the  length  of  the  tubercle  bacillus,  but 
thicker,  so  that  when  several  are  joined  together  they  look  at  first  sight  not 
unlike  streptococci.  When  fully  developed  the  ends  of  the  bacilli  are 
darker  and  thicker  than  their  central  portions  ;  sometimes  only  one  end  is 
enlarged.  Two  are  often  joined  together.  They  vary  considerably  in  shape 
and  size,  according  to  their  age  and  the  conditions  under  which  they  have 
grown  ;  thus  the  '  long  bacillus '  and  the  '  short  bacillus '  are  sometimes 
spoken  of ;  it  would  be  unsafe  to  say  that  the  presence  of  the  short  variety 
means  a  mild  attack  of  the  disease.  Recently,  chiefly  by  French  authors 
(Roux,  Yersin,  Barbier,  Sevestre),  the  micro-organisms  which  are  found 
associated  with  the  diphtheritic  bacilli  have  been  carefully  studied.  The 
most  important  association  is  with  streptococci,  the  strepto-diphtheria  of 
French  authors  ;  these  cases  correspond  with  the  septic  cases  of  scarlet 
fever,  with  which,  indeed,  they  have  a  close  resemblance.  The  presence  of 
streptococci  in  considerable  numbers  notably  increases  the  virulence  of  the 
attack.  Staphylococci  (aureus  and  albus)  are  frequently  associated  with  the 
D-bacilli,  the  attack  is  usually  more  benign  than  when  streptococci  are 
present.  Pneumococci  (Frankel),  Coli-bacilli,  Proteus  bacilli  may  also 
be  present,  the  latter  in  gangrenous  diphtheria.  The  chemistry  of  the  mem- 
branes and  the  poisons  formed  in  the  exudations  and  in  the  blood  have  been 
studied  by  Roux  and  Yersin,  and  more  recently  by  Sidney  Mailin  {Lancet^ 
March  26,  1892).  The  latter  observer  has  established  the  fact  that  during 
the  growth  of  the  bacilli  a  ferment  is  formed  which  is  capable  of  digesting 
proteids,  certain  albumoses  being  formed  which  act  as  virulent  poisons  on 
the  system.  These  albumoses  are  formed  locally  and  are  then  absorbed  into 
the  blood  ;  but  it  appears  the  ferment  is  also  present  in  the  blood,  and  by 
its  action  on  the  proteids  of  the  blood  and  tissues  albumoses  may  be  formed 
in  the  spleen  and  other  organs.  Similar  poisons  are  formed  when  the 
bacilli  are  cultivated  in  blood  serum  or  in  gelatine.  Roux  and  Yersin  have 
shown  that  if  the  nutrient  fluids  in  which  the  bacilli  have  grown  are,  after 
the  bacilli  have  been  separated  by  filtration,  injected  subcutaneously  into 
guinea   pigs,    death   takes   place   with  symptoms    of  toxaemia    in    twenty- 


Diphtheria  281 

four  hours.  If  small  doses  were  employed  and  injected  into  rabbits,  and  a 
fatal  result  did  not  take  place,  a  paralysis  was  often  left.  The  poison 
appears  to  give  rise  to  degeneration  of  the  tissues  ;  there  are  changes  in  the 
liver  cells,  the  muscular  fibres  of  the  heart  and  other  organs,  and  the  smaller 
motor  and  sensory  nerves.  In  the  peripheral,  nerves  the  white  substance 
of  Schwann  undergoes  degeneration,  and  in  places  disappears  ;  the  axis 
cylinder  is  also  affected,  but  in  less  degree.  It  is  this  peripheral  degenera- 
tion of  the  nerves  which  is  the  cause  of  the  paralysis  so  often  noted  after  an 
attack  of  diphtheria.  The  blood  is  profoundly  altered,  and  its  coagulability 
interfered  with  ;  hence  the  htemorrhages  and  purpuric  condition  seen  in 
malignant  cases  of  diphtheria.  The  cause  of  the  albuminuria  is  uncertain  ; 
it  may  be  caused  by  the  altered  state  of  the  blood,  or  be  due  to  the  fatty 
degeneration  which  the  renal  epithelium  undergoes  ;  the  amount  of  albumen 
present  is  in  most  cases  a  correct  index  of  the  severity  of  the  attack. 

From  the  above  facts  it  would  appear  that  the  D-bacillus  is  the 
primary  infective  agent,  and  that  during  its  growth  it  gives  rise  to  the 
fibrinous  exudation  ;  at  the  same  time  a  ferment  is  formed  resembling  pep- 
sine  which  is  capable  of  digesting  proteids.  This  proteid  digestion  goes  on 
both  in  the  membranous  exudation  and  also  in  the  blood,  albumoses  being 
formed,  which  play  the  part  of  virulent  poisons,  giving  rise  to  rapid  tissue 
degeneration  and  serious  changes  in  the  blood.  The  relation  between  the 
diphtheria  of  man  and  that  of  the  domestic  animals  is  interesting  and  im- 
portant. Some  of  our  domestic  animals  appear  to  suffer  not  infrequently 
from  diphtheria,  and  may  be  the  means  of  giving  rise  to  epidemics  of  human 
diphtheria.  The  observations  of  Klein  '  have  shown  that  diphtheria  may  be 
communicated  to  cows  by  subcutaneous  injections  of  cultivations  of  bacilli 
from  the  membrane  taken  from  cases  of  human  diphtheria.  A  soft  tender 
swelling  forms  at  the  seat  of  the  injection,  and  in  some  cases  at  least  a 
number  of  pimples  appear  on  the  udders,  which  pass  through  the  stages  of 
pustules  and  ulcers.  The  cows  suffer  more  or  less  from  fever,  and  anexten- 
sive  loss  of  hair  takes  place.  During  the  eruptive  stage  the  milk  of  some 
of  the  cows  was  found  to  contain  numerous  diphtheria  bacilli.  In  at  least 
two  epidemics  of  diphtheria  in  which  the  milk  coming  from  a  certain  dairy 
was  suspected  of  being  the  cause,  it  was  found  on  examination  of  the  cows 
that  they  Vere  suffering  from  an  eruptive  disorder  on  their  udders  similar  to 
that  produced  in  those  cows  which  had  been  inoculated.  Diphtheria  has 
been  produced  by  Klein  in  cats  by  feeding  them  with  cultures  of  the  D-bacillus 
in  milk,  and  epidemics  of  diphtheria  have  been  observed  in  cats.  Guinea 
pigs  are  the  most  susceptible  of  all  the  domestic  animals.  Fowls  suffer  from 
membranous  croup  which  closely  resembles,  if  it  is  not  identical  with,  human 
diphtheria. 

Pharyng-eal  Diphtheria. — The  tonsils,  uvula,  and  pillars  of  the  fauces 
are  the  favourite  sites  for  the  false  membrane  in  diphtheria,  and  in  by  far 
the  greater  number  of  cases  occurring  in  practice  these  parts  are  affected  in 
the  first  instance.  The  attack,  unlike  scarlet  fever,  usually  begins  insidiously. 
The  friends  notice  that  the  child  is  aiHng,  it  does  not  care  for  its  toys,  it  is 
peevish  and  fretful,  and  towards  evening  is  feverish.     Perhaps  there  is  some 

^  Twentieth  annual  report  of  the  Local  Government  Board. 


282  TJie  Specific  Fevers 

glandular  enlargement  at  the  angles  of  the  jaw,   or  a  discharge  from  the 
nose,  or  the  child  is  heavy  and  drowsy.      In  older  children  there  is  usually 
some  complaint  of  sore  throat  or  difficulty  in  swallowing  ;  the  child  feels  cold 
and  shivery,  and  sits  over  the  fire  trying  to  keep  itself  warm.     An  examination 
of  the  fauces,  if  made  within  a  few  hours  of  the  first  symptoms,  may  show 
nothing  very  distinctive  ;  there  may  be  some  swelling  and  excessive  redness, 
with  some  whitish  or  yellowish  exudation  in  points  or  patches,  but  it  may  be 
quite  impossible  to  decide  whether  the  case  is  one  of  diphtheria,  scarlet 
fever,  or  other  form  of  tonsillitis.     Usually,  however,  within  twenty-four  hours 
of  the  commencement  of  the  illness,  patches  of  membranous  exudation  may 
be  seen  on  the  inner  surfaces  of  the  tonsils  or  soft  palate  ;  these  are  whitish 
or  grey  and  opaque,  adhering  firmly  to  the  surface  so  that  they  cannot  be 
removed  by  brushing.      If  removed  by  forceps,  a  raw  bleeding  surface  is  left ; 
a  piece  of  membrane  when   removed  is  seen  to  be  tough  and  firm,  differing 
from  the  soft  cheesy  material  which  is  present  in  scarlet  fever  or  tonsillitis. 
The  temperature  is  rarely  high,  being  mostly  ioi°  to    103°   F.  ;  the  evening 
temperature  being,  as  a  rule,  a  degree  or  two  higher  than  the  morning  tem- 
perature.    In  a  day  or  two,  if  not  from  the  first,  membranous  exudation  may 
be  seen  on  the  uvula  or  the  pillars  of  the  fauces,  though  the  tonsils  may  be 
from  first  to  last  the  only  part  affected.     The  nasal  mucous  membrane  is  apt 
to  join  in  the  inflammatory  process  ;  a  semi-purulent,  often  bloody  discharge 
makes  its  appearance  at  the  nostrils  ;  the  child  makes  a  snoring  noise  when 
asleep,  on  account  of  the  obstruction  caused  by  the  swelling  of  the  mucous 
membrane  and  the  excessive  secretion.     An  examination  of  the  urine  during 
the  first  day  or  two  may  be  negative  as  far  as  albumen  is  concerned,  but  if 
a  daily  examination  be  made,  in  the  great  majority  of  cases  albumen  vary- 
ing in  amount  from  a  trace  to  one-half  will  be  found.     During  the  next  few 
days  fresh  patches  of  membrane  make  their  appearance  on  the  fauces,   the 
older  ones  becoming  loosened,  then  detached,  by  the  process  of  sloughing 
which  goes  on.     In  the  meantime  the  glandular  enlargement  and  tender- 
ness  become  more  marked,  and  the  neck  is  stiff  and  all  movements  are 
painful.     The  patient  becomes  weak,  anemic,  and  easily  exhausted  ;  there  is 
often  marked  foetor  of  the  breath.     In  favourable   cases,  after  the  first  few 
days  or  a  week  no  new  membrane  forms,  while  the  old  patches  disappear,  the 
swelling  of  the  glands  and  tonsils  becomes  less,  and  the  temperature  gradually 
falls.     The  albumen  also  gradually  diminishes  in  quantity  and  finally  dis- 
appears.    The  child  remains  weak  for  a  long  time,  convalescence  being  only 
slowly  established.     On  the  other  hand,  in  unfavourable  cases,  instead  of  an 
improvement  taking  place  at  the  end  of  the  first  week,   the  symptoms  both 
local  and  general  become  more  pronounced  ;  the  amount  of  urine  increases, 
the  pulse  is  weaker  and  perhaps  intermittent,  the  anaemia  is  profound,  the 
breath  very  offensive,  and  oozing  of  blood  takes  place  from  the  mouth  and 
nose.      The   patient  gradually  becomes    exhausted   and   refuses   his    food. 
During  the  last  hours  of  fife  there  may  be  total  suppression  of  urine,  drowsi- 
ness, and  extreme  depression  of  the  heart's  action. 

Mild  cases  may  occur  in  which  both  the  local  and  general  symptoms  are 
slight.  There  may  be  membranous  or  yellow-coloured  patches  on  the  tonsils, 
the  nasal  mucous  membrane  remaining  free  and  the  glandular  enlargement 
absent,  and  perhaps  only  a  trace  of  albumen  in  the  urine.     Such  patients 


Diphtheria  283 

may  be  seen  running  about  uitli  but  little  appearance  of  illness  ;  the  local 
lesions  may  disappear  in  a  few  days.  It  is  important  to  remember  that  in 
such  cases  paralysis  may  follow,  or  a  fatal  result  may  come  about  through 
cardiac  failure. 

Maligrnant  Diphtheria. — Of  severe  and  malignant  cases  of  diphtheria 
there  are  several  types.  The  attack  may  begin  insidiously  with  a  day  or  two 
of  slight  illness,  and  then  alarming  symptoms  of  cardiac  failure  may  set  in 
without  there  having  been  any  excessive  local  lesion.  In  other  cases  the  attack 
is  stormy  from  the  very  first,  perhaps  accompanied  by  vomiting,  and  closely 
resembling  scarlet  fever  in  its  mode  of  attack  (strepto-diphtheria  or  septic- 
diphtheria).  Within  a  few  hours  of  the  onset  there  is  extensive  swelling  at 
the  angles  of  the  jaws,  with  a  feeling  of  stony  hardness,  a  foetid,  sanguineous 
discharge  issues  from  the  nostrils,  and  it  is  difficult  to  get  a  view  of  the 
throat  in  consecjuence  of  the  swelling  and  difficulty  in  opening  the  mouth. 
The  tonsils  are  so  swollen  as  to  meet,  the  uvula  and  soft  palate  oedematous 
and  covered  with  more  or  less  sloughy-looking  membrane.  The  temperature 
is  usually  high,  being  103°  to  104°  F.,  and  the  pulse  and  heart's  action 
exceedingly  feeble.  In  the  course  of  a  day  or  two,  sometimes  less,  the 
cellulitis  extends,  the  cheeks  and  face  become  oedematous,  and  the  skin  pits 
as  low  as  the  clavicle,  or  even  over  the  sternum  and  chest  walls  ;  the  patient 
becomes  drowsy  and  cyanotic,  and  there  may  be  an  erythematous  rash, 
especially  about  ,the  neck  and  chest.  Purpuric  rashes  are  common  in 
malignant  cases.  Death  usually  occurs  in  a  few  days.  Such  cases  resemble 
malignant  scarlet  fever,  and  it  may  be  difficult  or  impossible  to  distinguish 
between  them  in  the  absence  of  a  characteristic  rash. 

TTasal  Diphtheria. — In  pharyngeal  diphtheria  the  inflammatory  pro- 
cess is  apt  to  spread  to  the  nasal  mucous  membrane,  especially  in  severe 
cases.  In  some  cases,  however,  the  nasal  mucous  membrane  is  the  first 
seat  of  the  exudation,  and  it  may  never  spread  to  the  tonsils,  though  it  is 
usually  to  be  found  to  involve  the  back  of  the  soft  palate  and  the  pharynx 
more  or  less.  In  nasal  diphtheria  no  membrane  may  be  distinguished 
during  life  ;  there  may  be  only  a  purulent  discharge  with  blood,  the  presence 
of  which  in  the  nasal  passages  obstructs  respiration,  giving  rise  to  a  bubbling 
or  sniffling  sound,  especially  during  sleep.  In  nasal  diphtheria  the  general 
symptonis  are  usually  quite  as  severe  as  in  faucial  diphtheria,  and  a  guarded 
prognosis  must  always  be  given.  In  cases  in  which  the  soft  palate, 
tonsils,  and  nasal  mucous  membrane  are  involved,  the  general  symptoms, 
including  the  depression  and  also  the  albuminuria,  are  well  marked.  In 
connection  with  this  form  of  diphtheria  we  must  bear  in  mind  there  is  a 
form  of  membranous  exudation  occurring  on  the  nasal  mucous  membrane 
in  measles  and  as  a  primary  disease  which  is  not  diphtheria,  but  which  runs 
a  much  more  favourable  course,  and  in  some  cases  at  least  the  membrane 
formed  is  thinner  and  less  adherent  than  it  is  in  diphtheria.  The  term 
'  Rhinitis  fibrinosa '  has  been  applied  to  these  cases.  In  all  cases  in  which  a 
child  is  feverish  with  a  discharge  from  the  nostrils  we  should  be  exceedingly 
suspicious  of  diphtheria,  especially  if  an  epidemic  prevails  at  the  time.  The 
inflammation  may  spread  from  the  nose  to  the  conjunctiva,  and  membrane 
may  form  on  the  palpebral  conjunctiva  and  much  purulent  discharge  may 
exude,  while  the  eyelids  may  be  much  swollen.     Membranous  conjunctivitis 


284  The  Specific  Fevers 

is  not  usually  diphtheritic,  but  due  to  pneumococci  (Frankel)  ;  the  local  dis- 
turbance may  be  severe,  while  the  constitutional  symptoms  are  slight. 

Iiaryng-eal  Diphtheria. — The  larynx  may  be  the  seat  of  the  local  mani- 
festations of  diphtheria  in  the  first  instance,  or  may  become  involved 
secondarily  to  the  fauces  or  other  part.  The  child  may  in  the  first  place 
suffer  from  sore  throat  and  feverishness  for  several  days,  and  then  a  metallic 
cough  and  some  dyspnoea  will  suggest  the  onset  of  laryngeal  complications. 
Less  often  some  other  part  is  the  first  to  be  involved  ;  thus  we  have  known  a 
patch  of  membrane  to  make  its  appearance  at  the  seat  of  an  eczema,  and 
then  a  few  days  afterwards  a  diphtheritic  laryngitis  supervene.  The  sym- 
ptoms present  in  laryngeal  diphtheria  will  be  found  described  (p.  332).  We 
must  constantly  bear  in  mind  that  the  obstruction  to  the  air  passages  caused 
by  the  presence  of  membrane  in  the  larynx  or  trachea  may  modify  or  over- 
whelm the  symptoms  of  the  disease,  but  we  must  not  overlook  the  tendency 
to  heart  failure  or  the  depression,  as  well  as  the  possibility  of  ursemia  or 
paralj'sis  supervening. 

Wound  Diphtheria.' — Diphtheritic  membrane  may  be  present  on  the 
lip,  tongue,  vulva,  and  glans  penis.  The  diphtheria  bacillus  is,  however, 
apparently  unable  to  flourish  on  normal  skin  ;  but  when  the  cuticle  is 
abraded,  as  after  blistering  or  in  eczematous  conditions  when  a  moist  raw 
surface  is  present,  the  bacillus  readily  flourishes.  Granulations  also  afford  a 
congenial  soil.  The  bacillus  may  be  inoculated  during  an  operation — as,  for 
instance,  in  excision  of  the  tonsils  ;  we  have  seen  a  case  in  which  membrane 
formed  within  twenty-four  hours  of  an  operation  for  hypospadias  at  the  seat 
of  operation,  a  fatal  result  occurring  in  a  few  days.  We  have  several  times 
seen  membrane  form  on  granulations  at  the  external  wound  in  empj^emata. 
In  one  of  these  cases  a  fatal  result  followed.  In  tracheotomy  for  diphtheria 
the  Avound  and  skin  around  the  wound  are  apt  to  become  the  seat  of  a 
fibrinous  deposit,  the  inoculation  taking  place  by  the  sputa  coughed  through 
the  tube.  In  newly  born  infants  the  granulating  surface  left  after  the  slouch- 
ing of  the  cord  may  become  the  seat  of  a  diphtheritic  inflammation. 

Co77iplications  and  SequelcE. — These,  though  less  numerous  than  those 
occurring  after  scarlet  fever,  are  hardly  less  important.  There  is  the  ex- 
tension of  the  inflammatory  process  from  the  fauces  to  the  neighbouring 
parts  already  referred  to — viz.  to  the  larynx,  nose,  middle  ear,  and  lymphatic 
glands  ;  the  latter  may  suppurate  besides  these.  The  most  noteworthy  are 
the  following  :  ist,  albuminuria  and  uraemia  ;  2nd,  pneumonia  ;  3rd,  disturbed 
innervation  of  the  heart  ;  4th,  paralysis. 

I.  iLlbuminuria  can  hardly  be  said  to  be  a  complication  of  diphtheria, 
inasmuch  as  it  is  almost  constantly  present  at  some  time  or  other  of  the  course 
in  faucial,  nasal,  and  laryngeal  diphtheria.  It  is,  however,  frequently  absent 
in  mild  cases  of  wound  diphtheria.  In  some  epidemics,  according  to  some 
observers,  albuminuria  is  much  commoner  than  in  others.  Our  experience 
certainly  has  been  that  albumen  is  rarely  absent  from  the  urine  in  cases  of 
true  diphtheria.  The  albumen  usually  makes  its  appearance  from  the  third 
to  the  eighth  day.  The  urine  is  mostly  normal  in  colour  and  in  amount,  but 
a  few  blood  corpuscles  and  epithehal  casts  may  be  found  on  microscopical 
examination  in  many  cases.  In  some  malignant  cases  htematuria  may  be 
present.     The  amount  of  albumen  present  forms  a  rough  indication  of  the 


DipJitJicria  285 

severity  of  the  case  ;  at  least  after  the  disease  has  existed  for  a  few  days. 
The  albuminuria  is  due  to  the  changes  effected  in  the  blood  or  in  the  renal 
epithelium  of  the  kidney  by  the  albumoses  or  toxalbumens  present  in  the 
blood,  and  the  amount  of  albumen  in  the  urine  represents  to  some  extent 
the  amount  of  poisoning  going  on.  Suppression  of  urine  and  unemia 
occur  at  times,  though  the  symptoms  present  are  not  so  distinctive  as  in 
scarlet  fever,  as  death  mostly  takes  place  before  the  symptoms  become  well 
marked.  Persistent  vomiting  with  a  falling"  temperature  should  always 
suggest  uraemia  ;  the  ui-ine  may  become  scanty  and  loaded  with  albumen, 
and  perhaps  cease  to  be  secreted  twenty-four  or  forty-eight  hours  before 
death.  CEdema,  muscular  twitchings,  or  ursemic  convulsions  are  rare.  In 
cases  which  recover  traces  of  albumen  may  remain  for  months,  but  chronic 
kidney  disease  as  a  result  of  diphtheria  is  uncommon. 

2.  In  severe  cases  of  diphtheria,  pneumonia  in  the  catarrhal  form  is 
common,  and  is  the  result  of  an  extension  of  the  inflammation  from  the 
fauces  or  larynx  to  the  lungs.  It  is  found  in  nearly  all  cases  of  fatal  laryn- 
geal diphtheria.     It  is  often  hajmorrhagic. 

3.  In  all  severe  cases  at  the  height  of  the  attack  the  pulse  is  feeble  and 
for  the  most  part  rapid.  It  sometimes  happens  at  this  time  that  the  heart's 
action  becomes  irregular,  intermittent,  or  abnormally  slow.  This  condition 
is,  however,  more  common  during  convalescence,  or  at  least  when  the  mem- 
brane is  disappearing  and  the  patient  apparently  improving.  There  is  often 
dyspnoea  on  the  slightest  exertion,  an  intermittent  cantering  action  of  the 
heart,  and  frequently  vomiting.  Sudden  cardiac  syncope  is  apt  to  take 
place.  This  may  occur  from  any  unwonted  mental  disturbance  or  from 
some  slight  exertion,  such  as  getting  out  of  bed  or  sitting  up  to  use  the 
chamber  vessel.  With  an  irregular  action  of  the  heart  there  is  often  dyspnoea  ; 
frequent  vomiting  and  slow  pulse  during  convalescence  from  diphtheria  are 
symptoms  of  great  gravity. 

4.  A  peculiar  form  of  paralysis  is  apt  to  follow  not  only  diphtheria,  but 
also  other  febrile  disorders,  as  typhoid  fever,  measles,  and  erysipelas  ;  it  is, 
however,  very  much  more  common  after  diphtheria.  The  paralysis  comes 
on  in  the  majority  of  cases  during  convalescence,  mostly  between  the  third 
and  fifth  weeks  ;  it  appears  to  follow  mild  cases  as  often  as  it  does  severe  ones. 
Its  usual  course  is  to  attack  the  soft  palate,  the  first  symptoms  being  a  return 
of  fluids  through  the  nose,  perhaps  only  a  few  drops,  and  a  nasal  twang  in 
speaking  ;  an  examination  of  the  soft  palate  shows  that  its  movements  are 
less  free  than  usual.  In  many  cases  a  slight  paresis  of  the  soft  palate,  which 
may  pass  off  in  the  course  of  a  week  or  two,  is  the  only  evidence  of  post- 
diphtheritic paralysis.  In  other  cases  the  paresis  is  much  more  decided ;  when 
the  patient  attempts  to  swallow  any  fluid,  much  of  it  returns  through  the 
anterior  nares,  and  some  may  perhaps  enter  the  glottis,  giving  rise  to  a  fit  of 
choking.  Other  parts  may  become  affected — the  pharyngeal  muscles  and 
oesophagus,  so  that  deglutition  is  performed  with  difficulty  and  the  patient 
has  to  be  fed  through  a  soft  catheter.  The  pupils  may  become  dilated  and 
unequal  from  paresis  of  the  circular  fibres  of  the  iris,  there  is  impairment 
of  vision,  from  the  ciliaris  muscle  being  affected.  The  paresis  may  extend 
to  any  or  all  of  the  voluntary  muscles,  so  that  the  patient  is  unable  to  stand 
or  sit  up  in  bed  or  even  raise  his  head.     Further,  the  respiratory  muscles, 


286  TJie  Specific  Fevers 

the  intercostals,  and  diaphragm  may  be  affected,  in  most  instances  speedily 
producing  a  fatal  result.  The  movements  of  respiration  are  laboured,  the 
patient  cannot  give  a  forcible  cough  or  cry  or  speak  loudly.  It  must  be 
borne  in  mind  that  in  post-diphtheritic  paralysis  there  is  rarely  complete 
paralysis,  but  rather  a  partial  loss  of  power,  combined  with  numbness  and 
sensations  as  of  prickings  with  '  pins  and  needles.'  Both  rectum  and 
bladder  may  also  become  paralysed,  but  this  is  not  common.  It  is  important 
to  bear  in  mind  that  paresis  may  follow  very  mild  cases,  so  that  the  patient 
may  be  seen  for  the  first  time  when  suffering  from  the  paresis  and  make  no 
mention  of  sore  throat.  Such  cases,  especially  if  there  be  no  paresis  of  the 
soft  palate,  may  be  very  puzzling,  and,  if  there  be  weakness  of  the  legs  and 
staggering  gait,  may  be  mistaken  for  tumour  of  the  cerebellum  or  ataxy. 
The  knee  reflex  is  absent  in  such  patients,  and  it  may  be  many  months 
before  it  makes  its  reappearance. 

Diagnosis. — The  diagnosis  of  diphtheria  in  a  typical  case  does  not  present 
much  difficulty,  especially  if  an  epidemic  is  prevailing.  The  false  membrane 
on  the  fauces,  and  the  presence  of  albumen  in  the  urine,  render  the  diagnosis 
of  diphtheria  practically  certain.  But  there  may  be  a  fibrinous  exudation  on 
the  fauces  with  more  or  less  fever ;  no  urine  can  perhaps  be  obtained,  or, 
if  obtained,  it  may  contain  no  albumen,  and  we  may  be  in  doubt  about  the 
diagnosis.  There  may  be  a  membranous  exudation  on  the  tongue,  lip,  nasal 
mucous  membrane,  or  conjunctiva,  with  no  marked  constitutional  symptoms, 
and  we  may  be  in  doubt  as  to  the  nature  of  the  case.  In  such  cases  clinical 
distinctions  may  entirely  fail  us,  it  being  uncertain  if  the  case  in  question  is 
one  of  mild  diphtheria  or  not.  We  have  to  depend  for  a  diagnosis  on  the 
detection  of  the  D-baciUus  in  the  membrane  or  secretions.  If  we  can 
by  microscopical  examination  or  by  cultivation  in  blood  serum  demonstrate 
the  presence  of  Loeffler's  D-bacillus  in  the  membrane,  the  diagnosis  is 
certain  ;  if,  on  the  other  hand,  only  streptococci  or  staphylococci  are  present, 
the  case  is  not  one  of  diphtheria.  In  cases  of  '  croup  '  or  ozsena  an  examina- 
tion of  the  secretions,  which  may  be  non-membranous,  may  often  decide  the 
diagnosis  in  favour  of  diphtheria.  The  disease  of  the  throat  most  likely  to 
be  confounded  with  diphtheria  is  croupous  or  membranous  angina  ;  usually, 
however,  in  this  disease  there  is  no  tendency  to  spread  to  the  nasal  mucous 
membrane  or  the  larynx,  and  there  is  less  often  glandular  enlargement. 
The  onset  is  more  sudden  ;  the  urme  is  free  from  albumen.  It  is  unnecessary, 
perhaps,  to  add  a  word  of  caution  in  not  excluding  diphtheria  without  very 
good  reason.  No  albumen  may  be  present  in  the  urine  at  the  time  of 
examination,  but  be  present  later  ;  there  may  be  a  complete  absence 
of  constitutional  symptoms,  and  yet  diphtheria  be  present.  A  mild  case  oi 
diphtheria  in  a  household  may  be  followed  by  a  malignant  one.  Diphtheria 
is  distinguished  from  scarlet  fever  by  the  absence  of  the  rash,  though  an 
erythematous  blush  is  present  in  a  few  cases.  In  malignant  strepto-scarlet 
fever  the  rash  may  be  absent,  and  the  glandular  swelling  and  sloughy 
condition  of  the  throat  closely  resemble  diphtheria  ;  there  may  also  be  a 
fibrinous  exudation  as  well  as  albuminuria.  Diagnosis  is  often  impossible. 
The  punctiform  rash,  however,  is  rarely  absent  in  scarlet  fever. 

Prognosis. — Diphtheria  is  one  of  the  most  fatal  diseases  with  which  we 
have  to  deal  ;  but  the  mortality  differs  widely  in  different  epidemics.     The 


DipJitJieria  287 

most  fatal  form  is  undoubtecll\-  the  laryngeal  ;  but  the  mortality  has  been 
considerably  reduced  by  the  use  of  antitoxme.  Strepto-diphtheria  in  its 
worst  forms  is  exceedingly  fatal.  Of  especially  bad  augury  are  large 
quantities  of  albumen  in  the  urine,  much  glandular  enlargement,  ex- 
cessive nasal  discharge,  a  foetid  state  of  the  fauces,  vomiting,  and  suppres- 
sion of  urine.  A  sudden  fall  of  the  temperature  to  subnormal,  and  an  inter- 
mittent pulse,  are  also  extremely  bad  symptoms.  Recovery  from  a  severe 
attack  in  which  there  is  great  depression  and  much  albumen  in  the  urine  is 
exceptional,  especially  in  a  child  under  six  years  of  age.  Suppression  of 
urine  in  diphtheria  is  nearly  always  fatal ;  though  in  one  case  seen  by  us, 
in  which  the  boy  had  suppression  of  urine  and  nasal  haemorrhage,  recovery 
finally  took  place.  A  fall  of  temperature  in  scarlet  fever  in  the  absence  of 
nephritis  is  a  good  sign  ;  it  is  by  no  means  so  in  diphtheria,  especially  if 
vomiting  be  present  and  an  increasing  quantity  of  albumen. 

The  mortality  of  cases  of  diphtheritic  paresis  is  very  high  in  those  cases  in 
which  the  diaphragm  and  intercostals  are  affected.  Cases  in  which  the 
paresis  is  confined  to  the  limbs,  soft  palate  and  muscles  of  the  eye  mostly 
recover.  Those  patients  who  live  five  or  six  weeks  after  the  onset  of  the 
paralysis  mostly  do  well. 

Treafi/ie/if. — The  indications  for  treatment  are  the  following  :  ist.  To 
isolate  the  patient  in  the  most  airy  room  obtainable.  2nd.  To  antagonise 
the  poisons  absorbed  into  the  system  or  formed  in  the  blood.  3rd.  To  apply 
antiseptics  to  the  fauces  or  affected  parts  to  prevent  decomposition  and  fcetor. 
4th.  To  support  the  strength  of  the  patient,  and  to  treat  symptoms  as  they 
arise. 

1st.  The  patient  may  be  isolated  by  sending  him  away  to  a  hospital  for 
infectious  diseases,  and  this  is  often  the  best  and  simplest  plan,  but  it  is  not 
always  possible.  If  the  patient  is  to  remain  at  home,  the  largest  room 
available  on  the  top  landing  should  be  selected,  or,  still  better,  two  rooms 
adjoining  one  another,  so  that  the  patient  can  be  moved  from  one  to  the 
other,  thus  allowing  the  unused  one  to  be  ventilated.  The  supply  of  a  large 
Cjuantity  of  fresh  air  to  the  patient  is  of  the  first  importance.  Ail  other 
children  in  the  house  should  be  sent  away,  bearing  iji  mind,  however,  that 
they  may  be  inciibati7ig  the  disease,  so  that  they  should  not  be  sent  where 
there  are  other  children,  or  to  a  distaftce  where  they  cannot  be  broiight  back- 
again  in  case  they  fall  sick.  Arrangements  should  be  made  for  disinfecting 
all  the  excretions  and  bed  linen  of  the  patient. 

2nd.  The  most  important  therapeutical  procedure  in  connection  with 
diphtheria  is  to  inject  antitoxic  serum.  No  time  should  be  lost  as  soon  as 
ever  the  diagnosis  is  made,  as  statistics  clearly  prove  that  it  is  within  the 
first  two  or  three  days  that  the  antitoxin  exerts  the  greatest  control  o\er  the 
disease.  It  is  wise  to  use  fresh  serum,  as  after  a  year  or  less  the  serum  appears 
to  lose  strength  rapidly  by  keeping.  The  usual  strength  of  the  serum  at 
present  on  the  market  is  1,000  units  per  c.c.  ;  the  average  dose  for  a  child 
above  two  years  of  age  is  i,  500  units.  In  a  severe  case,  2,000  units  should  be 
injected.  The  best  place  is  the  skin  of  the  flank  ;  the  skin  in  this  situation  is 
less  sensitive  than  it  is  on  the  abdomen.  The  surface  must  be  thoroughly 
washed  with  soap  and  hot  water,  a  suitable  syringe,  such  as  Roux's,  sterilised 
by  boilingj  a  fold  of  skin  nipped  between  the  fingers,  and  the  serum  injected 


288  The  Specific  Fevers 

into  the  subcutaneous  tissues.  The  dose  should  be  repeated  in  twelve  or 
twenty-four  hours.  The  injection  is  sometimes  followed  by  a  rise  of  tempera- 
ture, but  in  twenty-four  hours  the  temperature  falls,  the  membrane  tends  to 
separate,  and  the  patient  feels  better  and  is  brighter.  It  is  the  pure  diph- 
theria cases  in  which  the  effect  is  most  marked,  while  the  septic  or  strepto- 
diphtheritic,  in  which  there  is  much  sloughing  of  the  throat  and  cellulitis, 
are  but  slightly  influenced  or  not  at  all.  In  cases  of  diphtheria  which  have 
lasted  a  week  or  more,  the  improvement  is  small  or  nothing  ;  we  have  seen 
such  cases  die  within  a  few  hours  of  the  injection  without  the  slightest 
improvement  being  manifested.  It  is  certain  that  the  injection  of  serum 
cannot  cure  the  mischief  which  has  already  been  done  by  the  disease,  and 
in  malignant  cases  irreparable  and  fatal  mischief  may  occur  within  twenty- 
four  hours  of  the  commencement  of  the  attack.  In  any  case,  but  little  good  can 
be  expected  in  a  severe  case  if  the  injection  is  delayed  three  or  four  days.  The 
pain  and  discomfort  of  the  injection  have  been  materially  lessened  by  the  intro- 
duction of  the  concentrated  serums  of  a  strength  of  500  or  1,000  units  per  c.c, 
as  a  smaller  needle  can  be  used,  and  there  is  less  fluid  to  be  injected.  It 
is  less  common  now  than  it  was  a  year  or  two  ago  to  find  erythematous  rashes, 
urticaria,  and  swelling  of  joints  following  the  injection.  We  have  never  seen 
a  case  in  which  the  antitoxin  was  followed  by  any  alarming  symptoms  when 
used  early  in  the  attack  ;  when  used  in  severe  cases,  and  late  in  the  disease,  it 
is  only  too  likely  that  if  death  quickly  follows  after  the  injection  the  fatal 
result  may  be  attributed  to  it.  Experience  teaches  that,  in  children  under 
two  years  of  age,  the  serum  treatment  is  just  as  useful  as  it  is  in  older 
children.  The  experience  of  physicians,  both  in  Amer'ca  and  in  Europe,  is 
greatly  in  favour  of  the  serum  treatment,  and  there  can  be  little  doubt  that 
the  mortality  of  the  disease  has  been  lowered  by  its  use.  It  is  difficult  to 
express  this  accurately  in  statistics,  as  it  is  well  known  that  epidemics  of 
diphtheria  differ  extremely  in  severity,  and  the  mortality  with  the  serum  treat- 
ment differs  largely  according  as  to  whether  it  has  been  used  within  the  first 
day  or  so,  or  late  in  the  attack.  Then,  as  we  have  already  remarked,  the 
serum  injection  has  little  or  no  effect  on  septic  cases,  and  these  in  some 
epidemics  form  the  majority  of  the  cases.  The  prophylactic  dose  for 
children  is  500  units,  the  serum  being  used  for  this  purpose  in  hospitals, 
schools,  and  households  more  frequently  on  the  Continent  and  in  America  than 
it  is  in  this  country.  If  children  are  to  remain  in  a  household  in  which  a  case 
of  diphtheria  is  being  nursed  we  should  certainly  advise  their  being  injected. 
3rd.  During  the  last  few  years  it  has  been  recognised  that  our  means 
of  destroying  specific  organisms  present  in  the  throat  and  naso-pharynx 
are  extremely  limited.  The  action  of  antiseptics  contained  in  sprays  or 
local  applications  is  too  temporary  to  effect  much,  and  can  hardly  reach 
bacilli  which  are  embedded  in  membranous  exudation  or  are  subepithelial. 
The  most  we  can  effect  is  to  keep  the  throat  and  fauces  sweet  and  clean. 
Jt  is  evident  also  that  we  have  in  the  serum  treatment  a  far  more  powerful 
means  at  our  command  to  control  the  disease  than  by  any  local  applications. 
In  many  cases,  especially  in  young  children,  the  prolonged  fight  rendered 
necessary  in  order  to  cleanse  the  naso-pharynx  is  extremely  exhausting  to  the 
patient.  Warm  boric  acid  or  potass-permang.  irrigations,  as  recommended 
in  the  treatment  of  scarlet  fever,  are,  if  they  can  be  applied  effectually,  useful 


DiphtJieria  289 

in  cleansing ^^  the  throat  by  removing  mucus  and  fa;ticl  secretions.  The 
insufflation  of  powders  such  as  precipitated  sulphur,  boric  acid  and  iodoform, 
may  generally  be  managed  without  difficulty.  In  many  cases,  on  account  of 
the  fractiousness  of  the  patient,  we  must  be  satisfied  with  vaporising  carbolic 
acid  in  the  sick-room  by  means  of  heat  or  by  a  Siegel's  steam  spray  placed 
near  the  patient's  face.  For  wound  diphtheria  dry  applications,  as  finely 
powdered  calomel,  are  much  more  efficient  than  lotions  or  ointments.  With 
regard  to  the  medicinal  treatment  of  diphtheria,  we  prefer  to  use  the 
old-fashioned  tr.  ferri  perchlor.  in  three  to  five  minim  doses  every  four  hours. 
It  may  be  given  in  lemonade,  soda  watdr,  or  in  any  way  in  which  the 
patient  will  take  it.  We  do  not  think  that  either  chloi-ate  of  potash  or 
bichloride  of  mercury  is  the  least  use,  and  in  large  doses  they  are  dangerous. 
For  the  treatment  of  the  paresis,  hypodermic  injections  of  strychnine  and 
inhalation  of  oxygen  should  be  employed,  if  the  heart  or  respiratory  muscles 
show  any  sign  of  weakness.  Digitalis,  caffeine,  coca  wine,  alcohol,  should 
be  given  from  the  first  if  there  is  much  depression  of  the  system,  and  in  the 
worst  cases  alcohol  in  the  form  of  brandy  or  port  wine  must  be  given  with  a 
free  hand. 

4th.  The  diet  supplied  to  the  patient  must  consist  of  the  most  concen- 
trated form  of  nourishment  possible,  as  in  most  cases  there  is  great  chfficulty 
in  getting  him  to  take  food  on  account  of  the  discomfort  and  pain  in  swallow- 
ing ;  beef  juice,  peptonised  meat  preparations,  milk,  and  nutrient  supposi- 
tories may  be  needed.  If  there  is  swelling  or  cellulitis,  the  neck  should  be 
painted  with  glycerine  and  belladonna  and  covered  with  cotton-wool.  If  the 
glands  suppurate,  incision  and  proper  drainage  must  be  resorted  to.  The 
greatest  care  must  be  exercised  during  convalescence  to  supply  the  patient  with 
suitable  food  and  fresh  air,  and  to  prevent  any  exertion  on  his  part.  Paresis  of 
the  soft  palate,  general  paralysis,  and  failure  of  the  heart  may  come  on  at 
any  time  within  a  month  or  five  weeks  of  the  commencement,  even  in  mild 
cases,  and  the  practitioner  should  constantly  be  on  his  guard,  and  warn  the 
friends  against  allowing  any  excitement  or  unwonted  exertion.  During  con- 
valescence quinine,  strychnine,  and  iron  should  be  given.  The  continuous 
current  and  massage  is  of  use  in  the  paralysis  which  follows.  Change  to  the 
seaside  after  five  or  six  weeks,  reckoned  from  the  commencement  of  the 
attack,  will  prove  of  great  benefit. 

Quarantine. — This  should  be  maintained  for  four  weeks  in  mild  cases, 
and  six  weeks  or  more  in  the  more  severe  attacks.  It  is  important  during 
convalescence  to  spray  or  irrigate  the  patient's  throat  and  fauces  with  weak 
carbolic  or  boric  acid  solution  in  the  hope  of  getting  rid  of  any  remaining 
bacteria,  and  to  allow  the  patient  to  be  in  the  open  air  as  much  as  he  can. 
If  possible  a  bacterial  examination  of  the  secretions  of  the  patient's  fauces 
should  be  made  before  letting  him  loose  on  society. 

Disinfectiofi. — A  temperature  of  60°  C.  in  a  moist  atmosphere  is  sufficient 
to  destroy  the  D-bacillus.  For  disinfection  the  simplest  way  is  to  boil  the 
linen  removed  from  the  patient,  and  treat  his  clothes,  as  far  as  possible,  in 
the  same  way.  The  furniture  of  the  rooms  in  which  he  has  been  should 
be  scrubbed  with  hot  water  and  carbolic  soap,  and  the  floors  and  walls 
should  be  treated  m  like  manner.  Wearing  apparel  which  cannot  be  boiled 
had  best  be  destroyed. 

U 


290  TJie  Specific  Fevers 

IMCembranous  non-diphtheritic  Tonsillitis 

Practitioners  have  long  been  familiar  with  a  form  of  sore  throat  which 
mostly  occurs  in  epidemics,  which  in  many  ways  resembles  diphtheria,  but  for 
the  most  part  runs  a  milder  course,  and  is  not  followed  by  the  serious 
sequelee  which  so  often  follow  diphtheria.  Such  cases  have  gone  by  the  name 
of  diphtheritic  sore  throat  or  'croupous  angina.'  Recent  observations  have 
shown  that  the  D-bacillus  is  not  the  only  micro-organism  which  is  capable  of 
giving  rise  to  fibrinous  exudations,  but,  at  the  same  time,  no  other  micro- 
organism is  apparently  able  to  produce  the  depression,  albuminuria,  and 
paralysis  which  so  often  accompany  true  diphtheria.  Given  suitable  con- 
ditions, several  kinds  of  cocci,  especially  the  Streptococcus  and  Staphylococcus 
pyogenes^  the  coloii  bacillus,  and  the  pneuinococcus  of  Frankel  are  able  to 
produce  an  inflammatory  sore  throat  with  more  or  less  fibrinous  exudation  ; 
there  is  also,  according  to  Klein,  a  '  pseudo-diphtheria  bacillus '  closely 
resembling  the  true  bacillus  in  its  histological  characters,  but  incapable  of 
generating  during  its  growth  the  toxic  albumens  produced  by  the  true 
bacillus.  We  are,  however,  inclined  to  agree  with  those  who  look  upon  the 
pseudo-diphtheria  bacillus  as  the  true  diphtheria  bacillus  which  has  lost  its 
virulence.  Cases  of  pseudo-diphtheria  may  be  mild  with  only  slight  fever, 
but,  on  the  other  hand,  they  may  commence  with  vomiting,  high  fever, 
rigors,  and  the  tonsils  may  be  swollen  and  covered  with  a  membranous 
exudation.  The  mortality  is  not  high,  being  very  much  less  in  diphtheria, 
but  fatal  cases  do  occur,  sometimes  from  pneumonia.  The  clinical  course  of 
such  cases  may  be  very  much  like  what  has  already  been  described  under 
acute  tonsillitis.  Fibrinous  exudation  may  occur  in  other  places,  as  on  the 
nasal  mucous  membrane,  tongue,  lip,  vulva,  conjunctiva,  in  connection 
with  measles  or  other  diseases,  caused  by  septic  cocci  as  well  as  by  the 
D-bacillus. 

The  one  important  point  in  connection  with  these  cases  is  necessarily  the 
diagnosis.  If  we  can  certainly  exclude  diphtheria,  the  relief  to  all  concerned 
will  be  great.  Clinically  this  may  be  impossible,  and  a  diagnosis  may  only 
be  made  by  demonstrating  the  absence  or  presence  of  the  D-bacillus  in  the 
exudation  or  secretions.  But  difficulties  may  occur  here  as  long  as  the 
question  as  to  the  existence  of  a  pseudo-diphtheria  bacillus,  and  its  dia- 
gnostic characters,  is  unsettled.  It  must  be  remembered  that  the  failure  to 
find  the  D-baciUi  in  the  secretions  of  a  sore  throat  is  only  negative  evidence. 
The  local  treatment  of  pseudo-diphtheria  is  much  the  same  as  that  for 
diphtheria,  antiseptics  being  employed  to  destroy  the  cocci  and  to  keep 
the  fauces  and  mouth  sweet.  Carbolic  acid,  saHcylic  acid,  peroxide  of 
hydrogen,  and  chlorine  water  are  among  the  most  suitable.  On  the  skin, 
starch  and  salicylic  acid  powder  answers  very  well.  All  such  cases  should 
be  isolated  ;  indeed,  every  case  of  tonsiUitis  occurring  in  children  should  be 
regarded  with  suspicion,  and  kept  away  from  its  fellows  during  both  the 
febrile  and  convalescent  stages. 

Epidemic  Influenza.     '  Xia  Grippe  ' 

During  the  last  few  years  the  British  Isles,  in  common  with  the  con- 
tinents of  Europe  and  America,  have  been  visited  by  epidemics  of  a  peculiar 


Epidemic  Influenza  291 

zymotic  disease,  which  has  received  various  names,  but  is  best  known  in 
this  country  as  '  epidemic  influenza.'  These  epidemics  have  been  wide- 
spread, affecting  a  number  of  people  at  the  same  time,  have  come  to  an  end 
in  a  few  months,  and  then  reappeared  in  the  following^  year.  Epidemic 
influenza  is  very  infectious,  its  incubation  is  short,  and,  unUke  most  zymotic 
diseases,  one  attack  does  not  protect  from  attacks  in  subsequent  epidemics. 
It  is  very  prone  to  relapse.  In  some  epidemics  in  past  times  children  appear 
to  have  escaped  to  a  large  extent,  having  been  apparently  less  susceptible 
than  adults.  This  does  not  seem  to  have  been  so  in  the  recent  epidemics, 
for  individuals  of  all  ages  have  been  promiscuously  attacked,  children  having 
been  affected  in  common  with  adults,  though  the  mortality  among  the  former 
has  not  been  so  high  as  among  the  latter,  especially  in  the  pneumonic  form. 
In  some  epidemics  children  haveapparently  escaped  till  late  in  the  epidemic. 
The  incubation  is  usually  a  short  one,  often  not  more  than  a  few  hours, 
though  it  may  be  longer.  Certainly  instances  occur  in  which  a  very  i&\f 
hours  after  the  arrival  in  a  household  of  an  infected  individual  some  members 
of  the  household  are  quickly  attacked.  The  disease  appears  mostly  to 
spread  by  direct  contagion,  and  the  difficulty  of  controlling  an  epidemic 
arises  from  the  fact  that  a  number  of  mild  cases  occur  which  do  not  confine 
the  patient  to  his  bed  or  to  the  house,  so  that  while  going  about  his  business 
as  usual  he  readily  disseminates  the  disease.  R.  Pfeiffer  has  successfully 
cultivated  the  influenza  bacillus  on  blood-agar — that  is,  an  agar  medium 
containing  haemoglobin.  The  bacillus  occurs  in  large  quantities  in  the 
mucus  coughed  up. 

The  difficulty  in  describing  the  symptoms  consists  in  the  absence  of  any 
very  characteristic  ones,  and  in  the  multiplicity  of  symptoms  which  may  be 
present.  Moreover,  the  type  of  attack  appears  to  alter  from  time  to  time 
and  in  different  localities.  The  diagnosis  has,  in  point  of  fact,  often  to  be 
made  by  a  process  of  exclusion,  aided  greatly  by  the  knowledge  that  an 
epidemic  of  the  disease  is  prevailing  at  the  time,  and  that  perhaps  other 
members  of  the  household  have  recently  suffered.  As  a  result  of  the  difficulty 
of  diagnosis,  there  cannot  be  a  doubt  that  many  cases  in  which  the  diagnosis 
was  doubtful  have  been  described  as  influenza,  inasmuch  as  the  disease  was 
prevailing  at  the  time  ;  and  thus  it  has  come  to  pass  that  much  confusion  has 
arisen,  and  much  that  has  nothing  to  do  with  influenza  has  been  included  in 
the  descriptions  of  this  Protean  disease.  We  are  far  from  denying  that 
influenza  may  not  be  the  cause  of  diverse  forms  of  inflammatory  lesions  ; 
we  know  the  so-called  pneumonia  diplococcus  is  able  to  excite  not  only  a 
pneumonia,  but  also  an  otitis  and  meningitis,  and  it  is  by  no  means  impossible 
that  the  influenza  micro-organism  may  at  one  time  excite  a  pneumonia  and 
at  another  time  an  enteritis  or  meningitis.  The  cases  in  which  the  greatest 
difficulty  in  diagnosis  occur  are  in  infants  and  young  children.  It  is  so 
tempting  to  attribute  an  indefinite  febrile  attack  in  an  infant  to  teething  or 
dyspepsia,  and  so  difficult  to  be  certain  that  the  attack  is  due  to  influenza, 
unless  another  case  crops  up  in  the  same  household  to  give  us  the  clue.  In 
infants  we  have  not  the  advantage  of  the  patient's  account  of  himself  as  we 
have  in  adults,  so  that  the  diagnosis  is  often  only  come  to  with  difficulty.  One 
of  the  commonest  forms  of  the  disease  in  infants  and  young  children  is  the 
simple  febrile  type.     Practically  the  only  prominent  symptom  is  fever.     The 

u  2 


292  TJie  Specific  Fevers 

infant  is  noticed  to  be  hot,  there  is  a  temperature  of  102'  or  103°  F.,  the 
pulse  and  respirations  are  accelerated,  it  is  heavy  and  drowsy,  and  then,  after 
a  few  days  or  a  day  or  two,  the  temperature  falls,  and  the  infant  is  prac- 
tically well  again.  In  many  cases  the  course  is  protracted,  the  temperature 
going  up  every  evening"  for  a  week  or  more  before  it  finally  settles  down  to 
normal  again.  In  more  severe  cases  the  fever  suddenly  runs  up  to  104°  or 
105°  (it  maybe  with  a  convulsion  or  vomiting),  then  for  days  or  weeks  there 
may  be  fever  of  a  remittent  or  intermittent  type,  without  there  being  any 
pneumonia  or  tubercle  or  enteric  fever  to  account  for  the  temperature. 
Finally,  a  good  recovery  is  made.  These  cases  are  often  very  puzzling, 
especially  the  protracted  ones,  and  we  may  call  in  question  our  original 
diagnosis  of  influenza,  and  begin  to  fear  there  may  be  an  acute  tuberculosis 
in  progress  :  in  all  such  cases  it  is,  of  course,  necessary  to  repeatedly  examine 
the  lungs,  and  to  bear  in  mind  the  possibility  of  an  erratic  enteric  fever  being 
present  ;  there  cannot  be  a  doubt,  however,  that  in  young  children  a  fever 
of  the  intermittent  type,  lasting  two  or  three  weeks  or  more,  may  be  due  to 
the  influenza  bacillus.  Convulsions  and  vomiting  are  among  the  frequent 
symptoms  in  infants  and  young  children,  possibly  suggesting  an  acute 
menmgitis  ;  the  vomiting  is  often  exceedingly  troublesome  at  times,  but 
the  worst  cases  of  this  type  occur  in  older  children.  In  others  there  may 
be  bronchitis  and  pneumonia  of  a  depressing  and  fatal  character.  We 
have  not  seen  many  fatal  cases  in  infants  apart  from  pneumonia,  but  in 
one  case  that  we  know  of  death  occurred  in  two  days  as  the  result  of 
an  attack  which  was  accompanied  by  high  fever  and  depression.  The 
infant  was  ten  months  old  and  its  mother  was  suffering-  from  influenza  at  the 
time. 

In  older  children  the  attacks  approach  more  nearly  the  types  of  attacks 
witnessed  in  adults.  But  as  a  general  rule  the  neuralg-ic  pains  are  less 
marked,  as  also  are  the  rigors  and  backache.  The  attack  is  sudden,  the 
temperature  rurning  up  to  103°  or  more,  there  is  severe  headache,  vomiting, 
chilliness,  and  often  sore  throat.  The  conjunctivse  are  injected  and  the 
child  has  a  heavy  look.  Earache  is  often  a  marked  symptom.  After  twenty- 
four  or  forty-eight  hours  of  more  or  less  high  fever,  the  temperature  falls  to 
normal  or  it  runs  a  lower  course.  Some  cough  remains  for  a  few  days,  and 
often  marked  depression  ;  but  this,  in  our  experience,  is  not  so  severe  as  in 
adults.  An  examination  of  the  fauces  will  often  show  them  to  be  injected, 
and  the  tonsils  enlarged  and  covered  with  yellow  points  ;  there  may  be  some 
glandular  enlargement  secondary  to  the  tonsillitis.  To  add  to  the  difficulties 
of  diagnosis,  these  cases  sometimes  have  a  red  rash  closely  resembling 
scarlet  fever.  In  some  cases  which  we  have  seen,  we  had  no  doubt  that 
they  were  influenza  and  not  scarlet  fever — this  conclusion  being  arrived  at 
rather  from  the  fact  that  influenza  was  epidemic  and  there  were  cases  in 
the  same  household  and  neighbourhood,  than  from  being  able  to  decide 
from  the  symptoms  and  examination  of  the  patient.  Kramsytyk  records  an 
epidemic  of  influenza  in  Warsaw,  accompanied  by  a  red  rash  ;  on  the  other 
hand,  Filippow  records  sixteen  cases  in  which  influenza  was  complicated  by 
scarlet  fever.  There  may  be  an  attack  of  the  simple  febrile  type,  already 
described  as  affecting  younger  children.  A  persistent,  irritating  cough, 
almost  like  whooping  cough,  is  not  infrequent. 


Epidemic  Influenza    -Enteric  Eever  293 

One  of  the  most  serious  forms  which  the  disease  can  take  is  that  in  which 
vomiting  is  a  prominent  symptom.  In  some  of  these  cases  he  fever  is  high, 
perhaps  104°  or  105°  F.,  there  may  bedehriumor  an  excited  stateofthe  nervous 
system,  the  conjunctivic  are  injected,  and  the  child  restless  and  sleepless. 
Such  a  case  will  often  suggest  an  acute  meningitis.  The  vomiting  is  often 
continuous,  and  gradually  exhaustion  comes  on.  In  one  fatal  case  of  this 
character  which  we  saw  the  temperature  was  not  high,  not  exceeding  102°  F., 
and  this  for  a  time  made  the  diagnosis  of  influenza  doubtful.  In  the  worst 
cases  the  vomiting  continues  unrelieved,  and  the  child  dies  of  exhaustion  or 
in  a  convulsion.  At  the  post-mortem  no  gross  lesion  is  found,  but  there  is 
usually  venous  congestion  and  marked  injection  of  the  venous  capillaries. 
Another  serious  complication  is  pneumonia  ;  this  may  be  either  of  the 
croupous  or  broncho-pneumonic  type.  The  course  is  often  protracted,  and 
the  mortality  is  higher  than  in  the  ordinary  forms  of  pneumonia.  Empyema 
is  not  an  uncommon  result.  Less  commonly  there  is  a  catarrh  of  the  small 
or  large  bowel,  giving  rise  to  troublesome  diarrhoea  and  colic.  We  have 
seen  several  cases  of  acute  ileo-colitis  which  occurred  during  an  epidemic  of 
influenza,  but  we  could  not  for  certain  say  they  were  due  to  this  cause.  We 
have  seen  cases  that  certainly  resembled  enteric  fever.  Meningitis  has  been 
described  as  occurring  in  some  attacks  (G.  W.  Earle).  Sevei'e  otitis  is  not 
uncommon.  Relapses  are  common,  and  the  possibility  of  their  occurrence 
will  always  have  to  be  borne  in  mind.  We  have  known  death  to  take  place 
in  a  relapse.  As  a  rule,  the  depression  which  so  commonly  follows  an  attack 
of  influenza  in  an  adult  is  much  less  marked  in  the  case  of  children. 

Seqiielce. — Chronic  otitis  is  apt  to  be  left  by  influenza.  Various  nervous 
sequelae  may  occur,  more  especially  in  adults.  We  have  seen  cases  in  which 
an  irregular  and  intermittent  action  of  the  heart  was  left  by  attacks  of  influenza 
in  children.     Recovery  seems  always  to  take  place. 

Treatment. — The  patient  should  be  isolated,  and  confined  to  bed  in  a 
well-warmed  room.  As  long  as  the  fever  lasts  his  diet  should  consist  of 
fluids,  such  as  beef  tea  and  warm  milk.  As  a  routine  method  of  treatment 
we  generally  prescribe  a  mixture  contaming  salicylate  of  soda,  antipyrin,  and 
spirits  of  chloroform  (F.  50,  51).  If  the  fever  is  high,  vigorous  antipyretic 
measures  may  be  required  ;  to  this  end  warm  or  tepid  baths,  with  doses  of 
phenacetjn,  antipyrin,  or  antifebrin,  may  be  given.  Other  symptoms  must 
be  treated  as  they  arise.  The  most  difficult  cases  to  treat  are  those  in  which 
the  vomiting  is  a  constant  symptom.  In  these  cases  antipyrin  in  an  effer- 
vescing mixture,  iced  champagne,  and  small  quantities  of  raw  beef  juice  may 
be  tried.     In  the  continued  fever  quinine  may  be  given. 

Enteric  Fever 

As  a  general  rule  it  may  be  said  that  children  and  young  people  are 
more  susceptible  to  enteric  fever  than  are  adults,  and  they  usually  suffer 
from  ii  in  a  milder  and  less  complicated  form.  It  is  not  common  in  children 
under  three  years  of  age,  though  it  undoubtedly  does  occur  even  in  infants, 
and  may  be  fatal  ;  it  is  not  easy  to  say  at  what  period  of  life  it  is  most 
common,  as  statistics  of  fever  hospitals  are  apt  to  be  fallacious,  since  the 
milder  cases  are  certain  to  be  nursed  at  home,  and  children  suffering  from 


294  '^^^^  Specific  Fevers 

the  disease  in  a  mild  form  will  in  a  great  many  cases  never  enter  a  hospital 
at  all.  According  to  Collie,  ten  years  to  twenty  years  of  age  is  the  commonest 
time  for  an  attack ;  five  years  to  ten  years  of  age  ranking  next.  The  mortality 
at  all  ages  from  enteric  fever,  according  to  Murchison,  is  15  to  20  per  cent. 
In  children,  according  to  Barthez  and  Rilliet  and  Gerhardt,  10  per  cent.  In 
our  own  hospital  592  cases  have  been  treated,  with  48  deaths,  giving  a 
mortality  of  8  per  cent.  It  is  obvious  that  too  much  reliance  must  not  be 
placed  upon  these  figures,  as  in  the  different  hospitals  a  different  proportion 
of  severe  cases  maybe  admitted,  or  the  mild  and  abortive  cases  mayor  may 
not  be  reckoned  as  attacks. 

Enteric  fever  spreads  by  direct  contact  with  the  sick,  by  means  of 
emanations  from  both  fresh  and  stale  feeces,  possibly  also  by  the  breath,  by 
inhalations  of  sewer  gas  given  off  from  drains  into  which  the  excretions  of 
enteric  patients  have  been  thrown,  and  by  the  taking  of  drink  or  food  which 
has  become  contaminated  by  the  specific  bacilli.  There  is  reason  to  believe 
that  infection  may  be  carried  from  the  sick  to  the  healthy  on  the  fingers  or 
clothes  of  a  third  person.  The  evidence  that  enteric  fever  is  directly  con- 
tagious, the  disease  being  contracted  by  coming  in  contact  with  a  patient,  is 
too  strong  to  be  explained  away — notably  the  evidence  produced  by  Collie 
at  the  Homerton  Fever  Hospital  ;  and  in  our  own  hospital  hardly  a  year 
passes  without  one  or  more  probationer  nurses  contracting  the'  fever  from 
patients  they  are  nursing  ;  and  we  have  known  it  to  happen  that  patients  in 
the  same  ward  with  cases  of  enteric  fever,  who  have  never  been  out  of  bed, 
have  contracted  the  fever,  doubtless  by  the  bacillus  having  been  brought  to 
them  by  one  of  the  attendants.  It  appears  to  spread  in  this  way  in  the 
crowded  homes  of  the  poor,  where  one  member,  mostly  one  of  the  children, 
contracts  the  disease,  and  remains  at  home,  being  nursed  in  a  room  where 
others  sleep  ;  then  in  the  course  of  two  or  three  weeks  other  members  are 
attacked.  Indeed  no  disease  is  more  certain  to  spi'ead  in  the  crowded 
dwellings  of  the  poor  than  enteric  fever. 

Inciibatiojt. — Usually  fourteen  to  twenty-one  days. 

Symptoms  and  Course. — In  every  epidemic  cases  maybe  met  with  which 
are  so  mild  that  they  can  only  be  recognised  as  enteric  as  they  occur  in 
the  same  house.with  other  undoubted  cases.  In  such  cases  the  temperature 
may  be  from  first  to  last  intermittent,  being  perhaps  102°  or  103°  in  the 
evening,  and  falling  nearly  to  normal  the  following  morning  ;  evidently  these 
cases  were  included  by  the  older  writers  under  the  term  '  infantile  remittent 
fever.'  Other  cases,  which  begin  like  an  ordinary  attack,  abort  by  the  end 
of  the  second  week,  and  are  at  once  convalescent  without  going  through  the 
ordinary  three  weeks'  course.  In  other  cases  the  morning  remission  is  much 
more  marked,  being  perhaps  three  or  four  degrees  lower  than  the  evening, 
and  this  tendency  is  especially  shown  after  the  middle  of  the  second  week. 
In  these  mild  cases  the  patient  does  not  appear  ill  ;  in  the  morning  the  child 
will  be  seen  sitting  up  in  bed  playing  with  his  toys  ;  and  but  for  a  heavy  look 
about  the  eyes  and  a  glance  at  the  temperature  chart  over  the  bed,  it  would 
be  difficult  to  persuade  oneself  that  he  was  suffering  from  any  febrile  disease. 
Such  patients  are  often  brought  to  the  out-patient  rooms  of  dispensaries,  and 
are  not  considered  by  their  parents  as  anything  but  'out  of  sorts.'  There  is 
rarely  diarrhoea  in  the  milder  cases.      On  the  other  hand,  cases  of  great 


Enteric  Fever 


295 


severity  may  be  met  with  in  children,  the  fever  may  run  high  and  last  for 
many  weeks,  or  fatal  complications  may  supervene,  or  death  may  take  place 
early  in  the  disease  from  the  intensity  of  the  poison,  as  in  the  case  of  a  child 
of  three  years  coming  under  our  notice  who  died  as  early  as  the  eighth  day. 
Initial  Symptoms. — These  mostly  come  on  gradually,  though  exceptionally 
there  is  a  somewhat  sudden  onset  ;  the  fact  that  the  onset  in  any  case  has 
been  abrupt  does  not  certainly  negative  the  diagnosis  of  typhoid  fever. 
Frontal  headache  is  nearly  always  complained  of,  with  a  feeling  of  chilli- 
ness which  induces  the  patient  to  sit  overthe  fire  ;  there  is  usually  '  rambling  ' 
at  night,  less  often  aljdoniinal  pain,  diarrhoea,  and  epistaxis. 


sSSBSSEBBsr""™""""**""*"*""""""""*""" 


■inra^n^iBa 


Fig-  55- — Temperature  Chart  of  a  case  of  Mild  Enteric  Fever  in  a  boy  aged  9  years. 


Temperature, — In  an  attack  of  ordinary  severity  the  evening  temperature 
reaches  104°  by  the  fourth  evening,  continuing  to  reach  this  point  or  there- 
abouts once  daily  for  about  ten  days,  the  diurnal  remissions  usually  being 
1°  to  2°  ;  the  remissions  then  become  more  marked,  amounting  to  2°  or  3°,  the 
fever  gradually  subsiding  by  lysis,  and  of  an  intermittent  type,  remaining 
normal  after  the  twenty-first  day  (see  fig.  56),  though  perhaps  touching  normal 
a  day  or  two  before.  The  highest  temperature  of  the  twenty-four  hours 
is  usually  late  in  the  afternoon  at  4  or  5  p.m.  ;  later  in  the  attack  it  is  post- 
poned, and  reaches  its  highest  point  at  8  P.M.  or  midnight.  In  mild 
attacks  there  is  a  marked  tendency  to  remit  2°  or  3°  or  more  early  in  the 
attack,  and  to  abort  at  the  end  of  the  second  week,  in  a  way  which  is  rare  in 
adults. 

Hyperpyrexia  is  the  exception  in  children  ;  in  a  few  cases  a  temperature  of 


295  TJie  Specific  Fevers 

105°  or  even  106°  may  be  reached,  but  the  usual  maximum  temperature  during" 
twenty-four  hours  in  the  first  ten  days  is  103°  to  104°. 

The  temperature  curve  of  a  relapse  differs  very  much  in  different  cases  ;. 
it  is  usually  of  a  remittent  type.  It  is  hardly  necessary  to  insist  that  the 
temperature  should  be  always  carefully  taken  during  enteric  fever,  as  it 
affords  the  best  index  we  possess  of  the  severity  of  the  disease  or  the  patient's 
progress  to  recovery. 

Tongue  tifid  Mouth. — During  the  first  week  there  is  usually  nothing 
characteristic  about  the  tongue  ;  it  is  coated  with  a  thin  white  fur,  butjis 
clean  and  moist  at  the  edges  ;  there  is  often  a  glazed  clean  strip  down  the 
centre.  It  may  remain  moist  and  furred  throughout,  while  later,  especially 
in  cases  of  moderate  severity,  the  tongue  is  covered  with  a  brown  fur,  dry, 
with  a  brownish  glazed  central  strip.  Later  the  tongue  becomes  clean,  red 
and  glazed  ;  sometimes  there  are  superficial  ulcerations  on  the  surface. 
Sordes  very  readily  collect  on  the  teeth,  and  the  mouth  becomes  foetid  if 
not  cleansed. 

'  Abdomen. — The  abdomen  does  not  become  distended  till  the  end  of  the 
first  week  ;  during  this  time  the  distension  gradually  becomes  moi^e  and 
moi-e  marked  from  the  accumulation  of  gases  in  the  small  intestines  ;  at 
the  same  time  a  certain  amount  of  pain  on  deep  pressure  may  be  elicited 
and  gurgling  detected  in  the  iliac  fossae.  By  the  end  of  the  third  week,  if 
the  temperature  has  become  normal,  the  abdomen  becomes  less  rounded,  and 
gradually  returns  to  the  normal  condition.  In  mild  cases  the  abdomen  may 
be  normal  from  first  to  last. 

Spleen. — The  spleen  usually  enlarges  during  the  first  week  ;  the  earliest 
day  on  which  we  have  felt  it  to  be  enlarged  was  in  one  case  on  the  sixth  day. 
It  continues  enlarged  and  somewhat  soft  during  the  pyrexia  ;  according  to 
Jacobi,  if  the  spleen  remains  enlarged  after  the  temperature  has  fallen,  a 
relapse  is  to  be  feared.  In  some  cases  there  is  no  enlargement  to  be  felt 
during  life,  and  \S\& post-mortem  has  revealed  a  spleen  of  normal  size 

Bowels. — Typical  '  pea-soup '  stools  are  the  exception  in  children,  certainly 
diarrhcfia  is  not  usually  a  prominent  symptom.  The  bowels  may  be  con- 
stipated or  normal,  they  may  be  simply  loose,  or  there  may  be  the  watery 
pea-soup  stools  characteristic  of  the  disease.  As  a  rule  it  is  the  severe  cases 
which  have  troublesome  diarrhoea,  but  cases  may  be  severe  with  high  tem- 
perature and  prolonged  course  without  diarrhoea  being  present.  During  con- 
valescence constipation  is  apt  to  be  troublesome,  on  account  of  the  aton^^-of 
the  bowel  left  by  the  disease. 

Cerebral  Symptoms. — Slight  delirium  at  night  with  a  tendency  to  talk 
and  chatter  nonsense  is  common  ;  acute  delirium  like  that  present  in  typhus 
or  acute  pneumonia  is  rare.  After  a  severe  attack  the  mind  sometimes 
remains  weak,  a  condition  of  dementia  existing  for  some  weeks  ;  sometimes 
aphasia  is  left  ;  more  often  the  loss  of  speech  is  due  to  mental  weak- 
ness. The  prognosis  is  good,  the  mind  recovering  as  the  system,  gathers 
strength. 

Eruption. — The  characteristic  rose  spots  are  present  in  about  75  per  cent, 
of  the  cases.  The  spots  may  be  detected  by  the  end  of  the  first  Aveek,  rarely 
earlier  ;  fresh  spots  appear  daily  till  towards  the  middle  of  the  third  week  : 
they  may   go  on  longer,  into  the  fourth  or  even  fifth  week.     They  often 


Enteric  Fever 


'-97 


reappear  durin}^'  a  relapse.  Their  numbers  vary  from  two  or  three  to  many 
hundred,  so  that  the  child  has  a  freckled  appearance. 

Urine. — If  the  temperature  is  high  and  continuous,  albumen  in  slight 
quantity  is  mostly  present.  Indican  is  often  present.  The  urine  is  high- 
coloured  and  concentrated. 

Conipliciitions. — The  same  complications  that  occiir  in  adults  are  found 
also  in  children.  There  is  the  same  tendency  to  relapse,  there  may  even 
be  more  than  one.  Not  infrequently  the  relapse  is  more  severe  than  the 
primary  attack  ;  death  from  perforative  peritonitis  may  take  place  in  a 
relapse.  The  interpyre.xial  period  is  very  variable.  Thus  in  a  severe  case 
the  temperature  touched  normal  on  the  twenty-first  day,  was  then  inter- 
mittent till   the  thirtieth,  then  normal  till  the  thirty-fourth,  then  a  relapse 


12     13      14-     15      16      17     IS     19    20     21 


■  lllilBlrll 


'——————— — — "illBlTlP^— — — — — — — — — !!iS5aSS!H>l!™!i!HilH™HBHB"H 


\g 


■  ■■PBlll^lHP 


Fig.  56. — Temperature  Chart  of  a  case  of  Enteric  Fever  in  a  girl  aged  9  years. 
*  rose  spots  ;  t  spleen  felt. 

occurred,  the  temperature  varying  from  102°  to  104°,  till  it  reached  norma 
again  on  the  fifty-third  day  ;  recovery  followed.  In  another  case  the 
primary  fever  ended  on  the  nineteenth  day,  a  relapse  occurred  on  the 
thirtieth,  lasting  till  the  fiftieth.  In  another  the  primary  fever  ended  on 
the  twentieth,  the  relapse  occurred  on  the  twenty-eighth,  and  lasted  till 
the  forty-second.  In  another  the  primary  fever  ceased  on  the  twenty- 
fifth,  and  a  relapse  occurred  lasting  from  the  twenty-seventh  to  the  forty- 
si.xth. 

Epistaxis  is  not  uncommon  as  an  early  symptom,  and  is  of  no  import- 
ance. Small  quantities  of  blood  in  the  stools  are  common  during  the 
second  and  third  week,  and  if  small  in  quantity  need  not  be  a  cause  of 
alarm.     Smart  haemorrhag-e  fromtbe  bo-virels  is  rare,  though  serious  when 


298  TJie  Specific  Fevers 

large  in  amount,  yet  we  have  not  seen  a  fatal  case  result  from  it  in  a  child. 
We  have  seen  severe  heemorrhage  in  three  cases,  all,  however,  ending 
in  recovery.  In  one  case,  a  girl  of  eleven  years,  there  was  a  fall  of  tempera- 
ture on  the  twenty-seventh  day,  from  I03"2°  to  98-8°,  followed  by  a 
hiEmorrhage  of  10  oz.  of  blood  per  rectum  ;  another  haemorrhage  occurred 
on  the  thirty-first  day,  and  again  on  the  thirty-second  day  some  12  oz. 
were  passed  ;  she  eventually  recovered.  In  another  case,  in  a  boy  of 
twelve  years,  who  was  admitted  after  having  been  ill  a  month,  the  same 
evening  there  was  a  large  heemorrhage  per  rectum,  sufficient  to  blanch 
his  lips,  and  for  the  time  he  was  nearly  pulseless  ;  he  finally  recovered. 

Broncbitls  and  pneumonia  come  on  in  many  of  the  severe  cases  ;  they 
occur  quite  independently  of  a  chill  or  from  taking  cold  ;  they  are  due 
rather  to  stasis  of  blood  in  the  lungs,  mostly  at  the  bases,  and  possibly  also 
to  the  local  working  of  the  specific  bacillus  of  enteric  fever.  Diminished 
resonance  with  rales  and  rhonchi  are  detected  at  one  or  both  bases  if 
pneumonia  is  present.  The  temperature  is  usually  high,  and  the  pulse  and 
respiration  are  increased.  We  have  seen  death  take  place  from  this  cause 
on  the  nineteenth,  twentieth,  twenty-first,  twenty-third,  and  thirty-fifth  days. 
The  pneumonic  lung  is  of  a  purplish  colour,  has  a  solid  airless  feel,  and  is 
often  more  or  less  collapsed  on  section  ;  the  cut  surface  is  not  granular  like 
croupous  pneumonia,  but  smooth  and  dark  red.  The  lung  is  airless  and 
sinks  in  water. 

Pyaemia,  with  secondary  abscesses  in  the  lungs  and  elsewhere,  the  result 
of  septic  embolism  from  the  ulcers  in  the  intestines,  occasionally  occurs.  In 
four  of  such  cases  dying  in  the  Children's  Hospital,  the  course  of  the  disease 
was  acute,  with  hyperpyrexia  and  an  intermittent  temperature  towards  the 
close  ;  one  died  on  the  nineteenth  day  with  suppuration  in  the  parotid,  the 
others  -on  the  twenty-fifth,-twenty-ninth,  and  thirty-seventh  daj^s  respectively. 
At  the  post'inorteni  pyaemic  abscesses  due  to  infarcts,  and  pneumonia  were 
found. 

The  most  dreaded  complication  in  enteric  fever  is  perforation  of  the 
intestine  followed  by  peritonitis,  in  consequence  of  an  ulcer  penetrating 
through  the  wall  of  the  intestine.  This  complication  is  fatal  with  very  few- 
exceptions,  though  it  is  difficult  to  say  if  it  always  is,  as  cases  with 
symptoms  of  peritonitis  sometimes  recover,  and  it  is  not  unreasonable  to 
suppose  that  at  times  no  extravasation  may  take  place,  the  affected  portion 
having  become  glued  by  means  of  lymph  to  another  piece  of  intestine.  In 
four  of  our  cases  death  occurred  on  the  sixteenth,  twenty-second,  thirtieth, 
and  forty-eighth  days  respectively.  In  the  case  in  which  death  occurred  on 
the  sixteenth  day,  it  was  not  certain  if  it  was  the  sixteenth  day  of  the  piimary 
fever  or  of  a  relapse,  as  there  was  a  history  of  indefinite  illness  before  ad- 
mission. The  temperature  on  admission  was  normal,  though  there  was  some 
rhonchus  and  rales  were  heard  in  the  chest  ;  the  disease  ran  an  acute  course 
(fig.  57)  for  fifteen  days,  when  suddenly  there  was  collapse,  the  temperature 
falling  abruptly,  with  vomiting  and  abdominal  pain  ;  the  temperature  rose 
again  to  104°,  death  occurring  next  day.  A  perforation  in  the  ileum,  three 
inches  from  the  caecum,  was  found,  with  extravasated  fasces  and  general 
peritonitis.  In  all  the  cases  there  was  abdominal  pain  and  collapse  a  day  or 
two  before  death.     In  the  case  in  which  death  occurred  on  the  forty-eighth 


Enteric  Fever 


299 


day,  the  girl  had  been  ill  three  weeks  before  admission,  and  the  attack 
treated  in  the  hospital  may  have  been  a  relapse.  There  was  hyperpyrexia 
and  intermittent  fever. 

Some  cases  of  enteric  begin  with  tcjnsillilis  and  membranous  exudation 
on  the  tonsils  ;  occasionally  sloughing  tonsillitis  supervenes  in  the  course  of 
the  attack  ;  this  was  so  in  one  fatal  case,  in  another  a  membranous  laryngitis 
occurred  causing  death  on  the  twenty-first  day.  Otitis  may  occur,  and 
occasionally  a  fatal  result  follows  from  thrombosis  of  the  lateral  sinus  and 
pytvmia. 


1— WiytWIM^MM— ^W^MMI^BWi^BMiM^BMi— ^M— MliW^MMIM^BiBJM^M^B^B 


f  '§•  57-  —  Temperature  Chart  of  Enteric  Fever  ;   Peritonitis  ;  death  sixteenth  day  ; 
in  a  girl  of  9  years. 


Tuberculosis  may  complicate  the  course  of  enteric  fever,  or  it  may 
follow  as  a  sequela.  In  one  case  a  child  died  of  pneumonia  on  the  twenty- 
tirst  day  ;  tubercles  were  present  on  the  pleura  and  in  the  lung.  In  another 
case  a  girl  recovered  from  enteric,  the  temperature  becoming  normal  on  the 
twenty- sixth  day  ;  it  remained  normal  for  a  few  days  ;  she  continued  to  im- 
prove for  a  month,  though  the  temperature  went  up  occasionally  at  night. 
Then  hectic  fever  came  on,  with  vomiting,  and  she  died  comatose  three  weeks 
after  ;  \h^ post-mortem  showed  tubercular  meningitis  and  a  few  tubercles  in 
the  lungs. 


3O0  TJie  Specific  Fevers 

Diagnosis During  the  first  few  days  the  diagnosis  of  enteric  is  difificuh, 

often  impossible,  and  especially  in  children  typhoid  may  be  confounded  with 
the  feverishness  which  so  often  accompanies  dyspepsia  and  intestinal  catarrh. 
Children  are  frequently  brought  to  the  out-patients'  rooms  of  children's 
hospitals  with  indefinite  symptoms  and  feverishness  ;  a  tentative  diagnosis 
of  enteric  is  made,  but  in  a  few  days  the  symptoms  disappear  and  the  child 
is  practically  well  again.  Such  attacks  may  be  more  severe,  and  it  may  be 
impossible  to  say  whether  the  patient  has  had  an  abortive  enteric  attack  or 
not,  unless  there  are  undoubted  enteric  cases  in  the  household.  In  all  doubt- 
ful cases,  in  the  early  stages,  the  temperature  should  be  carefully  taken  every 
four  hours  and  a  cai-eful  exainination  made  for  rose  spots  and  enlargement 
of  the  spleen.  The  diagnosis  in  small  children  and  infants  is  extremely 
difficult,  on  account  of  the  many  causes,  such  as  patchy  catarrhal  pneumonia, 
intestinal  catarrh,  influenza,  and  tuberculosis,  which  may  give  rise  to  an  inter- 
mittent or  remittent  fever  ;  it  must  have  occurred  to  almost  every  medical 
man  in  practice  to  have  seen  babies  or  young  children  with  an  intermittent 
fever  lasting  two  or  three  weeks  or  more,  with  flatulent  abdomen,  but  no 
distinct  enlargement  of  the  spleen,  rose  spots,  or  diarrhoea.  Perhaps  there 
are  no  cases  of  enteric  in  the  neighbourhood.  Here  diagnosis  maybe  im- 
possible. We  have  never  seen  a  fatal  case  of  typhoid  in  an  infant  under  two 
years  of  age,  but  such  cases  have  been  recorded.  It  is  possible  that  some  of 
these  continued  febrile  attacks  are  due  to  some  other  form  of  bacillus.  The 
bacillus  coli  communis  has  been  suggested  by  some  French  authors  ;  they 
believe  it  may  take  on  a  malignant  action.  Widal's  serum  reaction  though 
not  apparently  absolutely  reliable  is  a  very  valuable  means  of  diagnosis. 

Acute  miliary  Tuberculosis  and  enteric  may  be  very  similar,  and  for 
a  week  or  two  the  diagnosis  may  have  to  be  held  in  abeyance.  Careful 
temperature-taking  every  four  hours  will  often  greatly  aid  the  diagnosis.  In 
acute  tuberculosis  the  fever  is  mostly  intermittent,  the  diurnal  ranges  being' 
perhaps  3°  to  5°  ;  there  are  no  true  spots,  rarely  diarrhoea  ;  miliary  tubercles 
may  occasionally  be  detected  in  the  choroid,  crepitation  may  be  heard  in  the 
lungs,  or  there  may  be  some  want  of  resonance  at  one  apex  ;  the  abdomen 
is  not  usually  rounded.  Tubercular  IVIeningritis  in  the  early  stages  may 
simulate  enteric.  A  child  who  is  seen  for  the  first  time,  recovering  from 
typhoid  fever,  being  anaemic,  wasted,  and  having  perhaps  some  cough  with 
rhonchi  heard  on  examining  the  chest  and  possibly  bedsores,  might  readily 
be  thought  to  be  suffering  from  Chronic  Tuberculosis.  If  there  is  diarrhoea  ' 
and  abdominal  tenderness,  the  two  diseases  at  this  stage  may  be  still  more 
alike.  A  careful  examination  of  the  lungs  would  generally  distinguish 
between  the  two,  as  in  chronic  tuberculosis  some  consolidation  at  the  apices  or 
elsewhere  would  usually  be  found.  PyEemia  may  resemble  enteric  fever, 
especially  in  those  cases  where  the  pytemia  is  secondary  to  some  bone 
disease  without  any  external  wound.  A  case  of  pyaemia  secondary  to  Pott's 
disease  of  the  spine,  with  abscesses  in  the  lungs,  which  came  under  our  care 
was  thought  for  a  few  days  to  be  enteric  fever  ;  but  the  daily  ranges  of  tem- 
■  perature  are  more  extreme,  the  type  more  markedly  intermittent  in  pyaemia 
than  typhoid.  A  rounded  distended  abdomen,  with  a  pimply  rash,  may  cer- 
tainly occur  in  other  diseases  than  enteric,  though  when  true  rose  spots  are 
present  they  are  characteristic. 


Enteric  Fever  301 

Morbid  Ana/oiny. — The  solitary  glands  and  Peyer's  patches  are  swollen 
in  catarrh  of  the  bowel,  enteritis,  also  in  scarlet  fever  and  septictemia,  as  well 
as  in  enteric  fever.  Ulceration  occurs  m  the  later  stages  of  enteritis,  ileo- 
colitis, and  tuberculosis,  as  well  as  in  typhoid.  In  a  typical  case  of  typhoid 
there  is  usually  no  difficulty  in  making  a  post-mortem  diagnosis,  as  the 
swollen  condition  and  ulceration  of  Peyer's  patches,  enlargement  of  the 
spleen  and  absence  of  tubercle  are  sutificiently  characteristic.  If  death 
takes  place  early  in  the  disease,  there  may  be  more  difficulty.  Eberth's 
typhoid  bacillus  is  with  difficulty  distinguished  from  other  bacilli  in  the 
ficces,  but  if  present  in  spleen  pulp  or  juice,  then  its  diagnostic  value  is  much 
greater. 

Treatment. — The  management  rather  than  the  medicinal  treatment  of 
typhoid  fever  is  of  the  greatest  importance.  The  patient  must  of  course  be 
put  to  bed  in  a  cool  room,  and  arrangements  made  for  both  night  and  day 
nursing  ;  it  is  needless  to  emphasise  the  importance  of  a  trustworthy  nurse 
at  night  to  feed  and  attend  to  the  patient's  wants  and  soothe  him  to  sleep. 
Sponging  with  warm  water,  to  which  some  Condy's  Fluid  or  Sanitas  has  iDeen 
added,  should  be  performed  every  evening  before  settling  the  patient  for  the 
night,  great  care  being  taken  to  cleanse  the  buttocks  and  anal  region, 
especially  if  the  patient  is  suffering  from  diarrhoea,  as  the  stools  are  apt  to 
be  smeared  about.  To  keep  the  patient's  back  scrupulously  clean  is  a  matter 
of  importance  in  the  prevention  of  bedsores.  The  patient's  mouth  must  be 
carefully  attended  to,  and  cleansed  by  means  of  a  paint  brush  or  rag  of 
decomposing"  food  and  foul  secretions  ;  the  more  ill  and  insensible  the 
patient  is,  the  more  important  does  this  become.  Condy's  Fluid  or  dilute 
solution  of  boro-glyceride  may  be  used  for  the  purpose.  The  diet  should 
consist  of  milk  diluted  with  barley  water  or  soda  water,  and  in  amount  should 
be  suited  to  the  age.  During  the  pyrexial  period  milk  is  better  taken  than 
beef  tea  or  other  savoury  foods,  which  as  a  matter  of  fact  are  c^uite  unneces- 
sary. The  more  thirsty  the  patient  is,  the  more  must  his  milk  be  diluted, 
lest  too  much  curd  remain  undigested  in  the  stomach  and  intestines,  and  give 
rise  to  flatulence  and  discomfort  ;  a  pint  and  a  half  to  a  quart  of  milk  daily 
will  be  sufficient.  An  excess  may  give  rise  to  diarrhoea  or  accumulate  in  the 
large  intestine  as  hardened  fteces.  In  the  later  stages,  when  the  tongue  is 
cleaning,  beef  tea  is  usually  taken  well,  and  forms  a  pleasant  change  of  diet. 
Where  milk  does  not  agree,  or  when  the  diarrhoea  is  troublesome, peptonised 
milk  or  Benger's  Food  should  be  given.  It  is  well  to  continue  the  fluid  diet  till 
a  full  week  after  the  temperature  has  become  normal.  Our  usual  practice  is 
to  allow  sops  in  the  milk  or  beef  tea  on  the  thirtieth  day,  at  once  discontinu- 
ing it  if  the  temperature  rises.  In  mild  or  medium  cases  alcohol  is  unneces- 
sary. No  medicine  is  required  ;  a  simple  saline  may  be  given.  The  treat- 
ment of  hyperpyrexia  must  depend  upon  the  effect  which  it  has  upon  the 
patient,  though  in  any  case,  if  the  temperature  rises  to  104°,  sponging  the 
head,  trunk,  and  limbs  with  water  at  60°  should  be  resorted  to,  or  the  cold 
pack  may  be  given,  provided  there  is  no  immediate  risk  of  peritonitis.  If  the 
temperature  is  not  kept  in  check  by  these  means,  but  the  fever  is  not  makint^- 
the  patient  drowsy  or  delirious,  no  other  means  need  be  taken,  except  perhaps 
applying  an  icebag  to  the  head.  Other  means  are  however  available,  such  as 
the  administration  of  phenacetin  or  quinine,  and  the  graduated  bath.     Anti- 


302  The  Specific  Fevers 

febrin  and  antipyrin  are  best  avoided,  as  too  depressing.  In  the  early  stages, 
with  due  care,  the  graduated  bath  is  useful  in  reducing  temperature  ;  in  the 
later  stages  it  is  conti'a-indicated  on  account  of  the  disturbance  to  the  patient 
which  it  entails.  The  patient  may  be  placed  in  the  bath  at  a  temperature  of 
ioo°,  and  cold  water  added  so  as  to  reduce  it  to  70°  or  80°,  though  it  is  rarely 
wise  to  allow  the  child  to  remain  in  longer  than  five  minutes.,  Excessive 
diarrhoea  should  be  checked  by  starch  and  opium  enemata,  or  Dover's  powder 
by  the  mouth  ;  sleeplessness  and  delirium  by  a  wet  pack  or  small  doses  of 
nepenthe,  the  latter  being  more  useful  than  bromides,  chloral,  or  urethan  ; 
abdominal  pain  or  tenderness  is  best  treated  by  nepenthe  in  free  doses  by  the 
mouth,  and  opium  fomentations,  while  the  food  and  liquids  taken  are  reduced 
to  a  minimum  compatible  with  safety,  pneumonia  by  stimulating  applications 
such  as  mustard  poultices  or  turpentine  stupe,  the  latter  being  used  with  great 
care  on  account  of  the  sores  apt  to  be  produced.  Any  signs  of  cardiac 
depression  must  be  combated  by  alcohol  in  the  form  of  mist,  vini  gallici,  or 
champagne,  or  by  caffeine,  ammonia,  ether,  or  digitalis. 

It  is  often  an  anxious  question  to  decide  as  to  whether  a  laxative  should 
be  given  when  the  bowels  are  constipated,  inasmuch  as  a  patient  is  rendered 
more  comfortable  by  a  free  action  of  the  bowels,  and  the  distension  and  dis- 
comfort are  lessened.  On  the  other  hand,  one  fears  that  the  peristalsis  set  up 
by  a  purgative  or  even  an  enema  may  do  irretrievable  damage  by  converting 
an  ulcer  into  a  perforation  or  tearing  down  adhesions  of  lymph  which  have 
formed.  At  the  same  time  it  must  be  remembered  that  hard  lumps  of  faeces 
irritate  the  bowel  and  fret  and  rub  the  ulcers,  and  in  some  of  the  worst  instances 
of  extensive  ulcers  in  fatal  cases  we  have  found  numerous  hard  lumps  of 
fteces  in  the  lower  part  of  the  ileum  and  large  bowel.  Some  doses  of  castor 
oil  during  the  first  ten  days  are  often  beneficial  if  the  bowels  are  confined  ; 
after  this  time  enemata  are  safer,  though  they  are  not  free  from  risk,  and  should 
certainly  be  avoided  if  there  are  signs  of  peritonitis.  If  severe  haemorrhage 
from  the  bowel  occur,  the  greatest  care  must  be  taken  to  give  the  child  only 
the  smallest  quantities  of  food  by  the  mouth  and  to  keep  him  as  quiet  as 
possible.  An  ice  bag  should  be  placed  on  the  abdomen  and  a  grain  of  ergotin 
given  subcutaneously  and  repeated  every  two  or  three  hours.  Opium  should 
be  given  in  small  doses  if  there  is  much  restlessness.  Turpentine  or  terebene 
in  two  or  three  drop  doses  in  mucilage  is  useful  as  a  stimulant  and  hsemo- 
static. 

Can  we  abort  enteric  fever  by  giving  laxatives  or  antiseptics  ?  This  is  a 
disputed  point,  inasmuch  as  enteric  frequently  aborts,  especially  in  children, 
without  the  help  of  drugs,  and  the  diagnosis  in  the  early  stage  is  difficult. 
We  certainly  believe  that  the  danger  of  setting  up  perforation-peritonitis  by 
giving  purgatives  has  rather  frightened  us  unnecessarily  into  the  too  sparing 
use  of  evacuant  remedies  such  as  calomel  or  castor  oil.  Small  and  repeated 
doses  of  calomel  or  castor  oil  during  the  first  ten  days  may  be  safely  given, 
and  in  many  cases  with  great  benefit.  We  are  less  inclined  to  the  heroic 
doses  of  calomel  advocated  by  some  physicians. 

During  convalescence  dyspepsia  and  constipation  are  frequently  trouble- 
some ;  flatulence  and  a  rise  of  temperature  are  very  apt  to  follow  any  excess 
of  starchy  or  any  indigestible  food,  especially  in  early  convalescence.  The 
food  should  consist  of  meat   essences,    of  broths,   jellies,    pounded    meat, 


Enteric  Fever —  'Fyphtis  303: 

chicken,  and  fish,  with  small  quantities  of  toast  or  stale  bread.  Cood  sherry 
with  a  grain  or  two  of  pepsine  and  some  licjuid  malt  extract  are  often  very 
useful.  The  constipation  is  usually  slow  in  disappearing  ;  purgatives  should 
be  avoided,  as  the  constipation  is  simply  due  to  wasting  of  the  muscular 
fibre  of  the  bowel  and  weakened  secretions.  In  this  condition  the  mineral 
acids,  strychnine,  cascara  sagrada  and  bitters  are  of  most  use. 

Typhus 

During  an  epidemic  of  typhus  children  suffer  ecjually  with  adults,  though 
the  mortality  is  exceedingly  small.  It  is  probable  that  the  fact  that  children 
usually  suffer  from  the  disease  in  a  mild  form,  and  but  few  die,  has  given 
rise  to  the  general  belief  that  children  are  less  susceptible  to  the  typhus 
poison  than  are  adults.  That  this  is  not  the  case  has  been  shown  con- 
clusively by  Dr.  Buchanan,  who,  after  referring  to  the  slightness  of  the  fever 
in  children,  says  :  '  When  inquiry  as  to  age  is  made  to  include  every  case  of 
attack,  children  and  adults  are  found  to  be  equally  susceptible  ;  the  actual 
incidence  may  even  be  observed  to  be  strongly  upon  the  young,  partly 
because  of  their  greater  numbers  and  partly  because  adults  are  frequently 
protected  by  previous  attacks.'  That  many  children  are  attacked  with 
typhus  is  shown  by  the  statistics  of  Homerton  Fever  Hospital  (given  by 
Collie),  for  out  of  711  admissions  of  typhus  to  the  hospital  during  the  period 
1871-  1880,  24  were  under  5  years  of  age,  54  from  5  to  9  years,  113  were 
from  10  to  14  years  of  age  ;  it  is  more  than  probable  that  the  proportion 
really  attacked  as  compared  with  adults  was  much  greater,  but  on  account  of 
the  mildness  of  the  fever  they  were  nursed  at  home  and  not  sent  to  hospital. 
Only  two  deaths  took  place  among  the  191  children  under  14  years  of  age  ad- 
mitted, while  the  total  mortality  was  ten  times  greater,  being  nearly  20  per  cent. 

Syinpioms  and  Course. — The  symptoms  and  course  do  not  differ  from 
those  seen  in  adults,  with  the  exception  of  their  usually  greater  mildness. 
The  attack  commences  with  headache,  pains  in  the  limbs,  drowsiness,  more 
or  less  shivering,  sometimes  vomiting,  rarely  diarrhoea.  This  history  closely 
resembles  that  often  obtained  in  scarlet  fever,  and  this  should  be  borne  in 
mind,  as  a  hasty  conclusion  as  to  the  nature  of  an  attack  may  be  a  wrong 
one.  If  seen  for  the  first  time  at  the  end  of  three  or  four  days,  there  is  a 
listless  expression  on  the  face  ;  it  is  flushed,  the  eyes  suffused,  the  conjunctiva 
injected  ;  the  child  may  answer  questions  if  spoken  to  sharply,  but  is  drowsy, 
semi-dehrious  and  irritable  if  interfered  with.  The  tongue  is  dry,  coated 
with  a  brown  fur  and  protruded  with  difficulty,  the  lips  are  black,  there 
are  sordes  on  the  teeth,  while  the  gums  easily  bleed.  An  examination  of  the 
lungs  reveals  the  presence  of  rhonchi,  perhaps  rales,  and  some  loss  of  re- 
sonance at  one  or  both  bases.  On  the  fourth  or  fifth  day  the  rash  usually 
appears  ;  the  skin  has  a  dusky  congested  appearance,  with  an  indistinct 
mottling,  in  addition  perhaps  to  petechial  points,  due  to  flea  bites  ;  for  our 
patients  with  typhus  usually  come  from  the  dirtiest  and  most  squalid  quarters. 
Perhaps  a  dusky  mottling  is  all  that  can  be  seen,  but  in  more  typical 
cases  the  rash  is  more  definite,  consisting  of  rose-coloured  spots,  or  maculse, 
larger  than  typhoid  spots,  and  with  more  ill-defined  margins,  scattered  over 
the  body.     According  to    Collie  they   are  first  seen  on   the  sub-clavicular 


304  The  Specific  Fevers 

regions,  along  the  lower  border  of  the  pectoralis  major,  on  the  wrists,  back  of 
the  hands  and  epigastrium.  We  have  sometimes  noted  the  rash  especially 
well  marked  on  the  dependent  parts  of  the  body,  sides  of  the  thighs,  and 
arms,  and  back,  extending  along  the  neck  on  to  the  cheeks,  and  present  also 
on  the  dorsum  of  the  feet.  The  temperature  is  usually  continuously  high. 
103°  to  104°,  the  pulse  small  and  weak,  perhaps  120  to  130,  and  there  is  some 
cough,  and  frequently  much  dehrium  or  wandering  at  night.  The  fever  may 
last  for  the  whole  two  weeks  ;  more  frequently  the  symptoms  undergo  marked 
amelioration  after  the  first  week,  and  possibly  the  temperature  dechnes  to 


im 


IPSk^l 


mi 


vaxk 


Fig.  58. — TemperaLure  Chart  of  Typhus  Fever,  ending  in  recovery.     Eliz.  G.,  aged  7  years. 


normal  by  the  eighth  or  tenth  day,  all  the  symptoms  becoming  milder  and  the 
rash  disappearing  without  becoming  petechial,  as  it  often  does  in  adults. 
The  rash  may  be  only  visible  for  a  few  days  or  may  fade  as  the  fever  becomes 
less.  While  the  above  description  applies  to  a  typical  case  in  a  child,  very 
severe  cases  may  sometimes  be  met  with,  though  far  oftener  the  symptoms  are 
decidedly  milder.  The  tongue  may  never  be  brown,  only  coated  with  a  white 
fur  ;  the  rash  may  consist  of  a  dusky  mottling  only  ;  there  maybe  drowsiness 
without  active  delirium.  The  late  Dr.  Tomkins  observed  in  some  of  his 
•cases  at  Monsall  Fever  Hospital  that  there  was  marked  torpor  and  lethargy 


Typhus  305 

during  the  first  few  clays,  so  that  tlie  child  was  with  difficulty  aroused  to 
take  food. 

It  is  obviously  important  to  recognise  typhus,  though  the  attack  may  be 
mild,  as  such  cases  are  of  course  infectious  and  may  spread  the  disease. 
Dr.  Tomkins  recorded  the  case  of  a  woman  who  contracted  a  fatal  attack 
by  sleeping-  with  a  child  suffering  from  mild  typhus  ;  the  cause  of  the 
child's  illness  not  having  been  recognised. 

Diagnosis. — The  fact  that  typhus  occurs  in  epidemics  and  is  apt  to  prevail 
in  the  overcrowded  and  poverty-stricken  quarters  of  a  large  city  often  helps 
the  diagnosis ;  but  occasionally  an  epidemic  breaks  out  in  a  school  or  in  the 
liomes  of  the  well-to-do.  The  onset  of  the  attack  may  suggest  scarlet  fever  ; 
the  high  fever,  drowsiness,  and  dusky  condition  of  skin  present  in  a  malig- 
nant case  of  the  latter  disease  might  render  the  diagnosis  doubtful  at  first  ; 
but  the  condition  of  the  tonsils  would  usually  clear  up  a  doubt  if  the 
characteristic  rash  of  scarlet  fever  was  not  present.  Nevertheless  we  have 
seen  a  case  fatal  in  two  or  three  days  that  gave  rise  to  some  doubt,  and  in 
the  absence  of  a  post-mortoii  was  never  cleared  up.  The  disease  most  likely 
to  be  mistaken  for  typhus  is  acute  pneumonia  (Collie)  ;  this  is  in  accord  with 
our  own  experience,  as  we  have  seen  cases  of  acute  '  cerebral  pneumonia,' 
with  physical  signs  delayed,  sent  into  hospital  as  typhus  ;  the  mistake  is 
likely  to  occur,  as  in  most  cases  of  typhus  some  rales  or  rhonchi  are  to  be 
heard. 

In  '  cerebral  pneumonia '  the  lesion  is  often  at  the  apex  of  the  lung  ;  if 
seen  on  or  after  the  fourth  day  of  illness,  and  there  is  bronchial  breathing 
or  dulness,  or  some  high-pitched  resonance  over  a  portion  of  lung  and  no 
rash,  the  disease  is  almost  certainly  acute  pneumonia.  A  dusky  or  mottled 
skin,  brown  dry  tongue,  rales  or  rhonchi  scattered  over  the  whole  lungs  or 
bases,  would  indicate  typhus.  Enteric  fever  may  be  mistaken  for  typhus, 
especially  when  acute,  but  the  insidious  nature  of  the  onset,  the  absence 
of  marked  delirium  or  torpor,  the  tenderness  on  pressure  over  the  abdomen, 
and  the  rose  spots  usually  suffice  to  make  a  diagnosis.  We  have  seen  some 
cases  of  typhus  where  there  was  a  good  deal  of  general  hypersesthesia  and 
muscular  tenderness,  where  pressure  on  the  abdomen  evoked  expressions  of 
pain. 

Prognosis. — This  is  mostly  good,  but  fatal  cases  sometimes  occur,  the 
children  succumbing  in  the  first  few  days  of  the  fever  from  the  intensity  of 
the  poison. 

Treatment. — That  of  fever  generally.  Sponging  with  Condy's  Fluid  should 
be  resorted  to  daily  ;  the  apartment  should  be  large,  airy,  and  warm  ;  stimu- 
lants are  required  in  all  but  the  mild  cases  ;  milk  and  other  liquid  nourish- 
ment must  be  given  in  suitable  quantities.  Directly  convalescence  has  set 
in  a  more  liberal  diet  may  be  allowed. 

Varicella 

Varicella  is  a  specific  infectious  disease  closely  resembling  modified 
smallpox,  though  perfectly  distinct  from  it.  There  are  still  a  few  who 
believe  varicella  to  be  a  variety  of  smallpox,  notwithstanding  the  many 
facts  which  point  in  a  contrary  direction  ;    these    may  be  summed  up  as 

X 


\o6 


TJic  Specific  Fevers 


follows  :  the  two  diseases  are  not  mutually  protective — children  who  have 
recently  had  smallpox  may  contract  varicella  ;  during  epidemics  of  one 
disease  the  other  is  not  usually  prevalent ;  smallpox  affects  all  ages,  vari- 
cella affects  children  almost  entirely  ;  inoculation  with  the  virus  of  smallpox 
produces  smallpox,  inoculation  with  the  contents  of  the  vesicles  of  varicella, 
when  successful,  produces  only  chicken-pox. 

Varicella  occurs  in  epidemics  in  schools,  workhouses,  children's  hospitals, 
and  among  the  poorer  classes  of  society  where  there  are  many  children  in 
constant  contact  with  one  another  ;  its  epidemics,  however,  are  not  so  wide- 
spread as  those  of  measles  or  whooping  cough,  nor  does  it  affect  so  large  a 
proportion  of  the  unprotected.  It  affects  children  almost  entirely  ;  thus  in 
584  cases  observed  by  Baader  in  Bale,  98  per  cent.  Avere  under  the  age  of 


Fig.  59. — Tern  perature  Charts  of  two  cases  of  Chicken-pox  in  children  of 
3i  years  and  18  months. 

ten  years,  and  65  per  cent,  below  five  years  of  age.  Adults  do,  however, 
occasionally  take  it.  We  have  several  times  seen  nurses  contract  the  disease 
from  children  suffering  from  it. 

Varicella  can  be  communicated  from  the  sick  to  the  healthy  by  inocula-* 
tion,  by  simple  contact,  or  by  infection  being  carried  by  a  third  person. 
Trousseau  failed  in  his  attempt  to  inoculate  ;  Steiner  seems  to  have  been 
more  successful,  succeeding  in  eight  cases  out  of  ten.  The  disease  is  most 
usually  communicated  directly  from  children  suffering  from  or  convalescent 
from  an  attack  ;  it  is  also  certain  that  the  infection  can  be  carried  by  means 
of  a  third  person,  and  remain  in  an  active  condition  in  clothes  for  many 
weeks,  inasmuch  as  sporadic  cases  of  the  disease  will  occur  in  hospital  wards 
in  patients  who  have  been  in  for  months,  and  where  no  cases  had  occurred 
previously  in  the  ward  for  a  long  interval. 


Varicella 


307 


Symptoms. — The  iyicubation  period  in  the  inoculated  cases  reported  by 
Steiner  was  eight  days  ;  when  contracted  in  the  ordinary  way  it  is  usually 
about  fourteen  days,  sometimes  a  day  or  two  more.  We  have  on  several 
occasions  had  an  opportunity  of  verifying  this.  There  are  usually  r\o  pre- 
monitory symptoms  ;  the  discovery  of  papules  and  vesicles  on  the  body  is 
usually  the  first  thing  noted  by  the  friends.  In  a  few  cases  there  is  a  diffuse 
redness  of  the  body  resembling  the  roseolous  rash  which  sometimes  precedes 
smallpox,  and  which  has  given  rise  to  the  suspicion  that  the  case  is  one  of 
scarlet  fever  ;  in  one  case  a  measly  rash,  preceding  the  vesicular  eruption, 
made  it  look  as  if  the  child  was  suffering  from  both  measles  and  varicella, 
but  of  this  there  was  no  confirmatory  evidence.  Frequent  micturition  was 
observed  in  one  of  our  cases  before 
the  rash  appeared.  The  premonitory 
fever  if  present  is  of  short  duration, 
\arying  from  a  few  hours  to  twenty- 
four  hours,  and  in  this  respect  varicella 
presents  a  marked  contrast  to  variola. 
The  temperature  is  not  as  a  rule  cha- 
racteristic, and  varies  with  the  acute- 
ness  of  the  attack,  mild  cases  with 
only  a  few  vesicles  being  feverless, 
severe  cases  with  a  great  number  of 
vesicles  being  accompanied  by  a 
temperature  of  104°  or  more.  The 
most  frequent  type  is  the  intermittent 

(fig-  59)-  _ 

The  rise  of  temperature  is  accom- 
panied by  an  accelerated  pulse,  coated 
tongue,  and  restlessness,  though  in 
mild  cases  these  may  be  absent ;  in 
a  few  hours  rose  spots,  resembling  the 
rash  of  typhoid,  appear  and  quickly 
iDecome  vesicular.  Probably  at  the 
time  the  first  examination  is  made  there 
will  be  both  rose  papules  and  minute 
blebs  or  vesicles  containing  clear  fluid 
and  surrounded  by  a  zone  of  red- 
ness. By  the  next  day  a  fresh  crop  of 
papules  and  vesicles  will  have  appeared,  the  vesicles  of  the  previous  day  are 
larger,  perhaps  some  of  them  have  aborted  and  commenced  to  dry  up. 
Fresh  crops  appear  on  the  third,  fourth,  fifth  days,  and  perhaps  later  still,  so 
that  when  the  attack  is  at  its  height,  as  it  usually  is  on  the  third  or  fourth 
day,  the  trunk  and  extremities  are  thickly  covered  with  vesicles  and  scabs, 
probably  also  a  few  pustules  where  there  has  been  some  scratching  and  the 
vesicles  have  burst.  The  contents  of  the  vesicles  are  at  first  quite  clear  ;  as 
they  enlarge  their  contents  become  more  cloudy,  but  not  purulent  unless 
the  vesicle  has  been  injured  and  part  of  its  contents  has  escaped.  The 
vesicles  are  mostly  unilocular,  their  upper  surface  is  convex  and  collapses  as 
soon  as  it  is  pricked,  though  in  some  cases  a  few  vesicles  may  be  seen  more 

X  2 


Fig.  60.— Varicella  Gangraenosa.  Child  aged 
2  years.  From  a  photograph  taken  after 
death.  The  patient  died  of  tuberculosis ; 
she  had  had  an  attack  of  Varicella  two 
months  before  death. 


2o8  The  Specific  Fevers 

or  less  flattened,  umbilicated,  and  multilocular,  closely  resembling  smallpox 
or  vaccination  vesicles.  The  number  of  vesicles  varies  greatly  ;  in  some 
cases  only  a  few  are  present,  in  others  there  may  be  many  hundreds.  They 
are  never  confluent.  In  the  majority  of  cases  the  vesicles  dry  up  and  scabs 
are  formed  at  their  site  ;  these  fall  off  in  the  course  of  a  few  days,  leaving 
clear  and  healthy  skin  beneath.  In  some  of  the  worse  cases  this  is  not  so  ; 
an  ulcer,  which  may  be  some  weeks  in  healing,  forms  beneath  the  scab  and 
thus  a  scar  is  left  not  unlike  those  following  severe  smallpox.  The  vesicles 
make  their  appearance  on  the  trunk,  limbs,  and  scalp  ;  they  are  generally 
more  sparely  present  on  the  face,  tongue,  and  soft  palate. 

The  prognosis  in  varicella  is  uniformly  good,  as  it  is  apparently  never 
fatal  in  a  previously  healthy  child.  In  weakly  and  tubercular  children  the 
varicella  vesicles  are  apt  to  be  followed  by  spreading  ulcers,  which,  joining 
one  another  and  taking  on  an  unhealthy  action,  sometimes  assist  in  bringing 
about  a  fatal  result.  Such  cases  have  been  described  by  Mr.  Hutchinson 
under  the  name  of  varicella  g^angrsenosa  ;  they  are  not  uncommon  in  the 
out-patient  room  (see  fig.  60).  The  gangrenous  action  is  usually  associated 
with  tuberculosis,  and  it  is  curious  that  in  all  fatal  cases  of  this  affection — as 
has  been  remarked  by  Dr.  J.  F.  Payne — tubercle  has  been  io\xr\^ post  mortem. 
Eustace  Smith  has  known  acute  tuberculosis  to  follow  varicella,  and  we  have 
also  seen  several  such  cases.  Nephritis  is  an  occasional  sequela,  as  first 
noted  by  Henoch. 

Diagnosis. — The  disease  with  which  chicken-pox  is  most  likely  to  be 
confounded  is  mild  or  modified  smallpox,  but  as  a  rule  no  difficulty  is  ex- 
perienced. The  points  of  most  importance  in  making  a  diagnosis  are  the 
absence  of  premonitory  symptoms  and  the  character  of  the  rash  ;  the  following 
table  shows  these  : 

Varicella  Varioloid,  or  modified  Smallpox 

Incubation. — Thirteen  to  sixteen  days.  Twelve  days. 

Premonitory  Fever. — A  few  hours.  Two  or  three  days. 

Premonitory  Sympt07iis. — Mostl}^  nil.  May  include  headache,  backache,  drowsi- 

ness, vomiting,  delirium,  convulsions. 
Rash. — Red  spots  becoming  vesicular  in  a        Red  shot-like  papules   appearing  on  face, 
few  hours  and  drying  up  in  three  or  four  wrists,  body,  limbs,  and  soft  palate  ;  in 

days,  leaving  crusts  ;  coming  out  in  crops  the  course  of  a  day  or  two  the  papules 

on  four   or   five  successive   days  on  the  becoming  vesicles,  and  developing   into 

scalp,   trunk,    limbs,  face,    and   mucous  pustules  by  the  eighth  day,  or  they  may 

membranes.     The    vesicles    are    mostly  dry  up  leaving  only  scabs, 

unilocular. 
Temperatii7-e. — Intermittent  in  character.  Sudden  rise,  reaches  its  height   when   the 

papules  are  fully  out ;  then  comes  a 
speedy  fall.  The  secondary  fever  is 
slight  or  absent  in  modified  cases. 

Occasionally  a  vesicular  syphilitic  eruption  may  simulate  varicella,  though 
such  eruptions  are  rare  in  congenital  syphilis,  and  when  present  take  the  form 
of  bullae  of  various  size  rather  than  vesicles.  In  one  case  which  came  under 
our  notice,  a  vesicular  syphilide  closely  resembled  varicella,  but  there  was  no 
fever,  and  some  brown  staining  followed  the  rash. 

Quarantine. — How  long  does  the  infection  last  in  varicella  ?  No  case 
should  be  considered  past  the  infection  stage  until  all  the  scabs  have  cleared 


Varicella —  Vaccinia  3  09 

away  and  the  skin  is  quite  smooth  and  normal.  This  is  usually  accomphshed 
in  three  or  four  weeks.  In  one  case  which  was  admitted  to  hospital 
suffering  from  psoriasis,  which  had  succeeded  the  eruption  of  chicken-pox, 
and  where  some  unhealed  ulcers  were  present,  the  admission  into  the  ward 
was  followed  by  an  outbreak  of  the  disease  some  fortnight  afterwards.  The 
child  admitted  had  had  chicken-pox  five  weeks  before. 

Trcal)iicnt. — Not  much  treatment  is  necessary.  The  child  should  be 
isolated,  and  preferably  be  kept  in  bed  if  there  is  a  copious  eruption.  A 
light  diet  should  be  given,  and  ointment  containing  some  tarry  or  carbolic 
compound  will  be  useful  to  apply  to  the  scabbing  vesicles. 

Vaccinia. — Performance  of  Vaccination. — The  safest  age  for  vaccinating 
infants  has  been  in  dispute,  some  preferring  to  vaccinate  within  a  few  weeks 
of  birth  and  before  the  monthly  nurse  leaves,  while  others  much  prefer  post- 
poning the  operation  till  three  or  even  six  months.  Inasmuch  as  unvacci- 
nated  children  under  one  year  if  they  contract  smallpox  almost  certainly  die, 
no  time  should  be  lost  in  vaccinating  infants  if  there  is  any  chance  of  their 
being  exposed  to  contagion — as,  for  instance,  if  smallpox  exists  in  the  house 
or  is  present  in  the  neighbourhood  in  epidemic  form.  On  the  other  hand,  if 
the  risk  of  their  being  exposed  to  contagion  is  small,  it  is  unwise  to  vaccinate 
during  the  first  few  weeks  of  life,  on  account  of  the  disturbance  of  the  general 
health  liable  to  follow  ;  infants  of  three  months  or  six  months  old  bear  the 
operation  better  than  infants  a  few  days  or  weeks  old.  We  prefer  the  age  of 
six  months.  It  is  of  importance  to  postpone  vaccination  beyond  the  end  of 
the  third  month  if  the  infant  is  not  robust,  or  suffers  from  diarrhoea,  malnu- 
trition, eczema,  intertrigo,  or  if  erysipelas  is  prevailing  in  the  neighbourhood. 
Revaccination  should  be  performed  at  or  before  puberty.  If  human  lymph 
cannot  be  obtained  from  an  infant  of  an  undoubtedly  healthy  family, 
glycerinated  calf  lymph  should  be  obtained,  and  if  the  latter  is  used,  any 
objection  to  the  performance  of  vaccination  on  the  ground  of  transmitting 
syphilis  and  other  diseases  is  obviated.  The  cuticle  should  be  removed  by  a 
few  scratches  of  a  needle  or  lancet  at  the  spot  where  a  drop  of  lymph  has 
been  applied.  After  vaccination  nothing  is  usually  to  be  seen  till  about  the 
third  day,  v/hen  there  is  some  itching  and  a  slight  redness  surrounding  the 
spot,  or  there  may  be  a  tiny  papule.  By  the  seventh  or  eighth  day  there  is  a 
flattened  vesicle  at  the  seat  of  puncture,  containing  clear  fluid  in  various 
loculi.  During  the  next  few  days  a  red  areola  forms  round  the  vesicle  and 
its  contents  become  cloudy  ;  by  the  tenth  or  eleventh  day  the  fluid  oozes  out 
and  forms  a  scab  on  the  surface,  which,  becoming  detached,  leaves  a  super- 
ficial ulcer,  which  takes  a  variable  time  to  heal  ;  a  permanent  cicatrix, 
which  is  circular,  depressed,  pale,  and  pitted,  is  left.  The  size  and  distinctness 
of  the  scar  will  depend  upon  the  ulceration  which  has  followed  the  pustule  ; 
if  the  latter  dries  up  without  an  ulcer  forming,  there  will  be  hardly  any  scar 
left.     There  is  often  some  febrile  disturbance  from  the  fifth  to  the  tenth  day. 

What  are  we  to  regard  as  the  best  vesicles  for  obtaining  lymph  from  ? 
According  to  Dr.  Hugh  Thompson,^  'they  are  such  as,  at  the  beginning  of 
the  eighth  day  (the  day  usually  chosen  for  taking  lymph,  although  not  always 
the  best),    show  the  punctures  made  in  vaccinating  well  healed  with  no 

'  '  Inoculation  for  Smallpox,'  by  Hugh  Thompson,  M.D.  ;  Glasgow  Medical  Journal, 
vol.  xxvii. 


3IO  The  Specific  Fevers 

scabbing,  the  vesicles  depressed  in  the  centre  and  elevated  at  the  margin, 
containing"  a  moderate  amount  of  lymph,  not  acuminated  ;  that  is,  ilat  in 
proportion  to  breadth,  and  not  having  lost  the  inequalities,  bosses  and  foveee 
— resulting  from  some  of  the  connections  between  the  epidermis  and  corium 
still  remaining  intact,  the  areola  incipient  or  only  slightly  developed.  The 
lymph  which  exudes  from  them,  on  being  pricked,  is  nearly  if  not  quite 
limpid,  somewhat  viscid,  moderate  in  quantity,  and  does  not  tend  to  run 
down  the  arm. 

'  As  a  general  rule  it  is  the  finest  children — those,  at  least,  who  are  such 
in  the  eyes  of  the  vaccinator  :  "  children  of  dark  complexion,  with  a  thick, 
clear,  smooth  skin,"  as  Seaton  remarks,  indications  of  a  strong  vigorous 
constitution — who  furnish  the  finest  vesicles.  At  the  same  time  care  must 
be  taken  to  see  that  the  child  is  in  perfect  health,  and  especially,  by  a  thorough 
examination,  that  it  is  free  of  all  skin  diseases,  and  more  particularly  all 
indications  of  syphilis,  among  the  most  persistent  and  obvious  of  which 
(excepting,  of  course,  manifest  syphilides)  are  chronic  coryza,  generally  from 
birth  ;  a  depressed  nose,  open  fontanelles,  hydrocephalic  head,  turgid  veins 
of  scalp,  tumid  lymphatic  glands.  Many  of  the  manifestations  of  syphilis 
disappear  under  treatment,  and  it  is  possible  they  may  have  thus  disappeared 
without  the  disease  being  thoroughly  eradicated  ;  but  it  is  rare  that  one  or 
more  of  the  above  may  not  be  found  if  searched  for.  It  is  superfluous  to 
caution  against  the  smallest  admixture  of  blood.' 

Complications  and  Sequelce. — These  are  fortunately  few,  though  numerous 
and  important  in  the  eyes  of  prejudiced  persons,  and  a  lengthy  list  could  be 
easily  compiled  if  all  the  evidence  collected  by  such  were  to  hold  good.  The 
most  important  are  the  following  :  (i)  Sypbilis  (see  infra)  ;  (2)  Erytbema 
and  Erysipelas.  There  may  be  an  unusual  amount  of  redness  and  hardness 
surrounding  the  pustules,  as  a  result  of  the  lymph  causing  more  irritation 
than  it  commonly  does  ;  this  may  spread  down  the  arm,  and  give  rise  to  some 
glandular  enlargement  without  there  being  any  erysipelas  present.  Ery- 
sipelas does  occasionally  occur.  The  erysipelas  coccus  may  gain  entrance 
into  the  wound  at  the  time  of  vaccination  ;  in  this  case  symptoms  will  pro- 
bably arise  within  a  few  days,  the  incubation  period  being  a  few  hours  to  two 
or  three  days.  It  is  impossible  to  say  for  certain  that  it  may  not  be  longer. 
In  a  case  which  came  under  our  notice  the  seat  of  the  vaccine  punctures 
began  to  become  inflamed  nineteen  or  twenty  hours  after  vaccination.  In 
such  cases  the  vesicles  and  pustules  often  mature  earlier  than  in  normal  cases, 
and  a  vesicle  may  be  present  on  the  second  day,  with  more  or  less  redness 
around  the  punctures.  The  patches  of  redness  and  oedema  are  migratory, 
as  in  other  forms  of  erysipelas- — that  is,  they  do  not  necessarily  remain  in 
the  immediate  neighbourhood  of  the  wound,  but  may  affect  the  face,  trunk, 
or  any  other  part.  The  mortality  of  vaccine  erysipelas  is  very  high,  most 
of  the  cases  being  fatal,  death  occurring  in  one  to  three  weeks.  It  has  un- 
fortunately happened  that  the  vaccine  has  been  taken  from  an  infant  suffer- 
ing from  or  incubating  erysipelas,  and  has  communicated  erysipelas  to  infants 
vaccinated  with  it.  Erysipelas  may  supervene  at  any  period  between 
vaccination  and  the  healing  of  the  pustules  if  the  infant  is  exposed  to 
the  infection,  the  cocci  becoming  accidentally  implanted  into  the  wound. 
(3)  Glandular  enlargement.     The  axillary  and  cervical  glands  may  enlarge 


Vacciiiia  3  I  i 

and  suppurate  during  the  maturation  of  the  pustules,  or  more  commonly  in 
the  second  week.  We  have  seen  several  cases  in  infants  with  chronically 
enlarj'-ed  and  case^iting  superficial  cervical  glands  of  the  left  side,  which  had 
commenced  to  enlarge  shortly  after  vaccination,  and  it  appears  likely  that 
in  infants  of  a  tubercular  or  'strumous'  tendency  vaccination  may  be  the 
predisposing  cause.  Similar  chronic  axillary  adenitis  is  also  occasionally  seen 
produced  by  vaccination,  just  as  by  any  other  irritation.  (4)  Cold  abscesses 
and  boils  may  form  in  various  parts  of  the  body,  as  they  will  at  times  after 
all  suppurations,  especially  in  tubercular  or  'strumous'  children.  (5; 
Various  rashes  occasionally  make  their  appearance,  mostly  towards  the  end 
of  the  week,  when  the  vesicle  is  maturing.  A  roseolous  rash  over  the  body 
and  arms,  which  is  fugitive,  disappearing  mostly  in  twenty-four  hours  ;  a 
vesicular  rash,  consisting  of  a  few  pimples  becoming  vesicular  ;  a  llcbenous 
rash  ;  and  patches  of  erythema  may  be  sometimes  present.  We  know  of 
no  evidence  which  directly  connects  eczema  with  vaccination  ;  it  is  very 
common  during  infancy  in  one  form  or  another,  and  it  is  not  surprising  that 
vaccination  often  gets  the  credit  of  producing  it.  An  impetlg-o  is  not 
uncommon,  having  been  produced  by  inoculation  of  the  secretions  from  the 
pustules  by  means  of  the  finger  nails. 

Varioloid  or  Post-vaccinal  Smallpox. — -Unvaccinated  children  suffer 
from  smallpox  in  as  violent  a  form  as  do  unprotected  adults  ;  indeed, 
according  to  Collie,  '  smallpox  is  very  fatal  in  unvaccinated  children  under 
five  years  of  age,  more  than  half  dying,  and  nearly  all  infants  under  one 
year.' 

Children  who  have  been  vaccinated  in  infancy  and  take  smallpox  usually 
suffer  from  it  in  a  modified  form  ;  there  maybe  no  rash  at  all,  or  more  often 
the  attack  aborts  and  the  vesicles  dry  up  without  passing  through  the  pus- 
tular stage,  the  secondaiy  fever  being  absent  or  only  slight.  Sometimes 
the  attacks,  according  to  Collie,  are  so  slight  that  diagnosis  is  impossible, 
except  from  the  fact  that  they  occur  after  exposure  to  infection  or  in  associa- 
tion w  th  cases  of  undoubted  smallpox.  The  premonitory  symptoms  may 
be  present — headache,  feverishness,  backache — which  disappear  before  the 
rash  appears,  the  attack  coming  to  an  end  without  any  papular  eruption.  It 
is  much  more  common  for  the  attack  to  abort  immediately  after  the  rash 
appears,  'secondary  fever  or  pustulation  being  absent.  The  premonitory 
symptoms  may  be  severe — -headache,  backache,  the  temperature  rising  to 
103°  or  104°  on  the  third  or  fourth  day,  a  copious  eruption  of  papules 
appearing,  perhaps  being  confluent  on  the  face,  to  be  followed  by  a  sharp 
fall  in  the  temperature  of  perhaps  4°  or  5°.  The  papules  become  vesicular  and 
dry  up  with  but  slight  if  any  pustulation,  and  the  child  is  convalescent  at 
once. 

The  temperature  chart  (fig.  61)  was  that  ot  a  child  aged  ten  years  who 
was  convalescent  from  scarlet  fever,  and  who  contracted  smallpox  while  in 
the  scarlet  fever  ward ;  the  only  source  of  infection  which  could  be  traced 
was  a  visit  of  her  mother  twelve  days  before,  the  latter  coming  four  miles 
from  a  district  where  smallpox  was  prevailing.  There  was  marked  head- 
ache but  no  pain  in  the  back  ;  on  the  third  day  an  erythematous  rash  was 
seen  on  the  body,  which  suggested  that  her  illness  might  be  scarlet  fever, 
though  she  had  passed  through  a  typical  attack  some  weeks  before  ;  on  the 


312  The  Specific  Fevers 

afternoon  of  the  same  day  a  few  tiny  papules  like  the  rose  spots  of  typhoid 
were  seen  on  the  abdomen  and  arms,  the  headache  was  severe  and  the  eyes 
suffused.  The  spleen  was  enlarged,  being  felt  i^  inch  below  the  ribs.  On 
the  fourth  day  the  face,  neck,  trunk,  and  limbs  were  covered  with  well- 
defined  papules,  many  confluent.  The  same  evening  the  temperature  fell 
from  104°  to  97°.  On  the  fifth  day  the  eruption  was  copious,  some  of  the 
papules  were  beginning  to  be  vesicular  ;  the  vesicles  quickly  began  to  dry 
up  and  scab,  no  true  pustules  appearing.  The  girl  made  a  good  recovery 
and  was  not  permanently  pitted. 

Diagnosis. — The   fact   that   smallpox  is  at  times  a  very   mild   disorder 
makes  it  important  that  it  should  not  be  overlooked,  inasmuch  as  a  mild  case 


Fig.  61. — Temperature  Chart  of  a  case  of  modified  Smallpox  in  a  girl  aged  10  years. 
Papular  rash  on  the  third  day,  becoming  vesicular  on  the  fifth. 

as  well  as  a  more  severe  one  may  be  the  means  of  spreading  the  disease. 
Diagnosis  is  hardly  possible  in  the  absence  of  a  papular  eruption,  or  the 
purpuric  spots  of  the  malignant  form. 

Treatment. — The  treatment  is  that  of  fevers  generally. 


^Vhooping'  Cougrh 

Etiology.,  &-r. —Whooping  cough  is  an  infectious  disease  which  is 
characterised  by  a  catarrh  of  the  air  passages  and  a  peculiar  spasmodic 
cough.  It  prevails  in  epidemics  which  are  both  widespread  and  prolonged, 
though  sporadic  cases  are  generally  present  in  large  centres  of  population. 


Whooping  Co2ig]i  3 1 3 

There  is  no  disease  which  is  more  certainly  infectious  than  whooping  cough, 
in  the  sense  that  if  those  who  are  unprotected  by  a  previous  attack  come  in 
contact  with  those  suffering  from  it  they  are  almost  certain  to  take  it.  If 
one  member  of  a  household  is  attacked,  all  the  other  members,  both  children 
and  adults,  who  are  unprotected,  take  the  disease.  If  it  enter  a  court  or 
alley,  it  is  tolerably  certain  that  all  the  unprotected  inhabitants  will  suffer. 
It  is  almost  certain  to  spread  in  a  similar  way  in  a  school  or  convalescent 
home.  It  is,  however,  a  curious  fact  which  we  have  often  noticed,  that 
whooping  cough  does  not  appear  to  spread  to  any  great  extent  in  hospital 
wards  in  which  the  children  are  in  bed  and  the  cubic  space  great  (the  same 
fact  has  been  noticed  by  Dr.  Sturges  and  Dr.  Goodhart),  and  it  would  almost 
appear  that  close  contact  with  the  infected  individual  so  as  to  inhale  his 
breath  was  necessary  to  give  the  disease.  It  is  impossible  dogmatically  to 
deny  that  the  poison  of  whooping  cough  can  be  conveyed  on  the  person  or 
by  clothes  to  a  distance  and  so  infect  the  healthy  ;  but  it  is  certainly  excep- 
tional ;  the  common  way  in  which  it  spreads  is  by  direct  contact  with  the 
sick.  A  \ery  short  contact  is  all  that  appears  to  be  necessary — such,  for  in- 
stance, as  a  child  meeting  another  for  a  moment  in  the  street  or  in  a  shop  ; 
several  instances  of  attacks  contracted  in  this  way  have  come  under  our 
notice.  The  epidemics,  like  those  of  measles,  appear  to  occur  in  large 
cities  every  eighteen  months  or  two  years.  It  has  been  asserted  that  there 
is  some  definite  relation  between  these  two  zymotics,  as  they  frequently  pre- 
vail epidemically  together  or  one  immediately  preceding  or  following  the 
other  ;  it  is  very  doubtful  if  this  association  is  anything  more  than  accidental, 
as  they  both  are  apt  to  recur  every  eighteen  months  or  two  years.  The 
whooping  cough  epidemic  lasts  longer  and  more  slowly  reaches  its  height  than 
the  measles  epidemic.  Like  measles,  whooping  cough  seems  to  prevail  at  all 
seasons  of  the  year  ;  but,  as  one  would  naturally  expect,  it  is  more  fatal  in  the 
colder  months  of  the  year  than  in  the  warmer  months,  in  consequence  of  the 
broncho-pneumonia  which  is  so  apt  to  supervene  if  the  child  takes  cold. 
The  mortality  is  mostly  high  among  very  young  and  weakly  children,  while 
in  older  children  it  is  rarely  fatal.  During  the  decade  1878-1887,  3,669  cases 
of  whooping  cough  were  treated  in  connection  with  the  children's  dispensary, 
with  281  deaths,  or  a  mortality  of  7-6  per  cent.  Of  these,  217  or  'j']  per  cent, 
were  under  two  years  of  age,  63  or  13  per  cent,  were  from  two  to  five  years 
of  age,  and  only  one  fatal  case  occurred  in  a  child  over  five  years  of  age.  It 
is  certain  that  these  figures  do  not  represent  the  total  mortality,  as  they  do 
not  necessarily  include  those  who  die  some  months  later  of  tuberculosis 
and  gastro-intestinal  atrophy. 

Incubation. — It  is  difficult  to  fix  the  latent  period  with  precision,  as  the 
onset  is  gradual  and  the  symptoms  are  often  indefinite.  It  is  usuaUy  seven  to 
fourteen  days  before  the  child  begins  to  cough,  and  another  week  or  ten  days 
before  the  characteristic  '  whoop '  is  heard.  This  makes  an  interval  of  two  to 
three  weeks  between  being  infected  and  commencing  to  '  whoop.' 

Symptoms  a?td  Course. — The  course  of  the  disease  is  marked  by  three 
stages:  (i)  The  catarrhal  or  premonitory  stage;  (2)  The  convulsive  or 
spasmodic  stage  ;  (3)  The  stage  of  decline  or  cojivalescettce.  These  stages,  it 
is  needless  to  say,  are  not  well  marked,  but  one  gradually  succeeds  the  other, 
and  this  is  especially  true  with  regard  to  the  third. 


314  '^f''^  specific  Fevers 

The  catarrhal  stage  begins  with  the  symptoms  of  a  feverish  cold  and 
tickling  dry  cough,  which  is  not  readily  relieved  by  ordinary  remedies.  The 
cough  is  especially  apt  to  recur  at  night,  and  it  is  remarked  on  by  the  friends 
as  being  more  than  usually  troublesome,  the  child  coughing  and  straining  as 
if  to  relieve  a  persistent  irritation  in  the  throat.  The  cough  keeps  it  awake 
at  night  or  it  wakes  up  coughing  and  fails  to  get  to  sleep  for  some  hours. 
During  the  day  the  child  may  appear  well,  or,  on  the  other  hand,  the  appetite 
fails  and  he  looks  pale  and  poorly.  The  cough,  if  not  paroxysmal  from  the 
first,  becomes  so  in  the  course  of  a  few  days,  before  the  actual  whoop  is  heard. 
There  is  usually  some  degree  of  fever  at  night,  and  dry  rhonchus  may  often 
be  heard  on  listening  to  the  chest.  The  first  stage  may  be  complicated  with 
bronchitis  or  pneumonia.  In  young  children  or  infants  the  convulsive  stage 
sometimes  begins  with  a  convulsion  or  series  of  convulsions. 

The  Convulsive  Stage. — ^The  cough  now  comes  not  only  in  paroxysms, 
but  there  is  a  distinct  whoop  ;  there  are  a  numberofshort  forcible  expiratory 
efforts,  as  if  an  attempt  was  being  made  to  expel  some  irritating  matters, 
followed  by  the  long-drawn  characteristic  inspiration  which  is  technically 
called  a  '  hoOp '  or  '  whoop,'  or  in  some  parts  of  the  country  a  '  chink.'  It  is 
perhaps  hardly  right,  at  any  rate  when  the  second  stage  is  well  established, 
to  speak  of  the  expiratory  coughs  as  '  efforts  ;  '  the  child,  prompted  by  a 
peculiar  tickling  sensation  in  the  throat,  attempts  to  reHeve  it  by  coughing, 
but  in  a  moment  the  coughing  goes  on  in  spite  of  any  voluntary  effort  to 
repress  it,  so  that  the  child's  face  becomes  congested  and  the  facial  veins 
distended,  before  the  inspiratory  act  takes  place,  and  the  air  rushes  into  the 
air-passages  and  lungs  through  the  narrowed  glottis.  Fit  after  fit  of  cough- 
ing will  often  follow  one  another,  till  the  child  vomits  or  a  rush  of  stringy 
mucus,  perhaps  streaked  with  blood,  pours  out  of  its  mouth  an  d  nose. 
In  the  worst  cases  the  distress  occasioned  by  these  fits  of  coughing 
is  extreme,  and  the  child  dreads  their  recurrence,  not  only  on  account  of 
their  discomfort,  but  from  the  aches  and  pains  it  suffers,  by  reason  of 
the  over-strained  and  weary  respiratory  muscles.  To  a  weakly  child  the 
disease  is  necessarily  a  formidable  one  ;  the  exhaustion  produced  by  the 
constant  muscular  efforts,  the  frequent  vomiting  which  prevents  a  proper 
amount  of  food  from  being  assimilated,  together  with  the  intestinal  catarrh 
which  in  a  greater  or  less  degree  accompanies  it,  often  reduce  the  child  to  a 
feeble  and  emaciated  condition.  It  can  easily  be  imagined  that  forty  or 
fifty  attacks  of  coughing  every  twenty-four  hours  produce  great  muscular 
exhaustion,  and  affect  the  child's  vital  powers.  In  milder  cases,  where  the 
fits  of  coughing  do  not  exceed  twelve,  the  child  may  appear  quite  well 
between  the  paroxysms,  and,  though  perhaps  vomiting  after  the  cough,  it  is 
quickly  ready  for  another  meal,  with  sharpened  appetite.  Fever  is  mostly 
present  in  the  second  stage  in  variable  degree,  especially  at  night.  An 
examination  of  the  chest  will  generally  disclose  bubbling  rales  in  the  larger 
tubes,  the  secretion  being  freer  than  in  the  first  stage. 

The  Stage  of  Decline. — After  a  variable  period  of  four  to  six  weeks,  during 
the  latter  portion  of  which  the  attacks  of  ^coughing  have  been  diminishing, 
the  characteristic  whoop  disappears,  and  convalescence  may  be  said  to  be 
established.  Mostly  the  paroxysmal  character  of  the  cough  remains,  and 
often  the  vomiting"  ;    gradually  the   bronchial  catarrh  disappears,  and  the 


Whooping  Cough  3 1  5 

cough  ceases,  though  it  is  \ery  likely  to  retuin,  and  the  whoop  along  with 
it,  whenever  fresh  cold  is  taken. 

Cflmplicatio7ts. — By  far  the  conimonest  is  some  form  of  broncho- 
pneumonia ;  pleurisy  and  empyema  are  not  unfrcquent.  There  is  nothing 
specially  characteristic  about  the  broncho-pneumonia  of  whooping  cough  ;  it 
is  usually  double,  is  very  apt  to  be  generalised  rather  than  '  patchy,'  and 
tends  to  resolve,  or  slowly  passes  into  a  subacute  or  chronic  state.  Croupous 
pneumonia  is  not  uncommon  in  older  children  who  take  a  chill  during  con- 
valescence, and  may  be  followed  by  empyema.  Empyema  and  atelectasis 
are  very  apt  to  occur  in  connection  with  bronchitis  in  small  and  rickety 
children.  Young  children  are  sometimes  convulsed,  the  convulsions  being 
due  to  asphyxia,  and  perhaps  mening-eal  bsemorrhagre  ;  drowsiness  and 
coma  are  usually  due  to  the  same  causes.  We  have  seen  a  temporary 
hemiparesis  arise  during  whooping  cough.  Cerebral  symptoms,  whether 
convulsions  or  drowsiness,  are  of  grave  import.  Intestinal  catarrh  and 
diarrhcKa  of  a  mucous  character  are  also  common  ;  the  catarrhal  condition 
of  the  air  passages  extends  to  the  intestines,  and  large  quantities  of  mucus 
are  secreted,  which  prevent  the  digestion  and  assimilation  of  food,  and  cause 
a  rapid  passage  of  the  food  through  the  intestines.  The  child  passes  small 
mucoid  stools  many  times  a  day,  is  feverish  and  rapidly  wastes.  Sometimes 
the  diarrhoea  is  of  a  dysenteric  character.  Tuberculosis,  especially  of  the 
bronchial  and  intestinal  glands,  is  a  sequela  rather  than  a  complication,  and 
usually  follows  some  months  later.  A  wasting  during  the  third  stage  is 
oftener  due  to  intestinal  catarrh  or  chronic  broncho-pneumonia  than  to 
tuberculosis.  Among  the  minor  complications  are  ulceration  of  the  fraenum 
linguse,  stomatitis,  and  sores  about  the  nose  and  lips.  Small  conjunctival 
hsemorrhages  are  very  common.  The  child  often  remains  for  a  long  time  in 
a  weakly  state  of  health,  and  may  take  long  to  regain  its  former  strength. 
Permanent  deformity  of  the  chest  may  remain  as  a  legacy  left  by  an  attack 
of  whooping  cough. 

Diagnosis. — Often  no  diagnosis  can  be  made  in  the  early  stages,  and  this 
is  the  more  unfortunate  as  there  can  be  no  doubt  that  the  disease  is  infectious 
during  this  stage.  The  fact  that  whooping  cough  occurs  in  epidemics  will 
often  aid  us  in  coming  to  a  conclusion.  Difficulty  may  often  arise  in  more 
chronic  cases  in  which  there  is  a  paroxysmal  cough  followed  by  more  or  less 
of  a  stridulous  sound,  as  to  whether  such  are  specific  and  are  to  go  into 
quarantine.  The  diagnosis  will  turn  largely  on  whether  any  cause  for  the 
spasmodic  cough  can  be  discovered  as  well  as  on  the  history  ;  if  there  has 
been  previous  wasting,  and  there  is  some  evidence  of  tuberculosis  of  the 
lungs,  enlarged  mediastinal  glands  would  be  suspected  as  the  cause  of  the 
spasmodic  cough.  Diagnosis  is  often  difficult  in  infants,  as  also  it  sometimes 
is  in  older  children,  who  may  have  whooping  cough  without  any  characteristic 
'  whoop  ; '  the  '  whoop '  may  also  cease  when  pneumonia  supervenes. 

Prognosis. — The  fact  that  the  mortality  is  vastly  greater  in  children 
under  two  or  three  years  of  age  than  it  is  in  older  children  must  be  borne  in 
mind  in  forming  a  forecast  of  results.  The  prognosis  in  the  case  of  an  infant 
or  a  weakly  child  of  eighteen  months  or  two  years  of  age  is  very  uncertain, 
and  death  may  occur  suddenly  during  a  fit  of  coughing  from  convulsions 
or  spasm  of  the  glottis.      The   prognosis   is   always   rendered  grave  by  the 


3 1 6  The  Specific  Fevers 

presence  of  broncho-pneumonia  ;  the  latter  when  it  follows  whooping  cough 
is  more  fatal  than  when  non-specific.  Whooping  cough  during  the  winter 
months  is  always  more  Hkely  to  be  complicated  with  chest  disease  than  in 
the  summer  ;  and  while  this  is  especially  true  of  the  poorer  classes,  it  holds 
good  also  to  a  lesser  extent  in  the  better  housed  classes  of  the  population. 
The  presence  of  rickets  affects  the  prognosis  unfavourably.  The  diagnosis 
between  chronic  broncho-pneumonia  and  tuberculosis  and  between  chronic 
intestinal  catarrh  and  mesenteric  disease  is  very  difficult  ;  but  the  tubercular 
diseases  are  much  more  likely  to  follow  at  a  distance  with  a  period  of  com- 
parative health  intervening,  while  the  simpler  forms  are  more  likely  to 
complicate  or  immediately  follow.  A  chronic  pneumonia  often  clears  up, 
and  the  child  recovers,  and  a  subacute  intestinal  catarrh  may  not  improbably 
do  the  same.     Death  in  rare  cases  occurs  from  sheer  exhaustion. 

Quara?iti7ie. — Six  weeks  is  usually  stated  as  the  time  the  infection  lasts, 
dating  from  the  commencement  of  the  whoop  :  but  in  all  cases  it  is  wise  to 
keep  up  the  quarantine  till  all  cough  has  ceased  and  the  child  is  quite  well. 
If  the  cough  or  even  whoop  recur  after  a  period  of  undoubted  health,  there 
is  no  fear  of  infection. 

Pathology  and  Mo7^bid  Anatomy. — The  epidemic  prevalence  of  whooping 
cough  and  its  infectious  character  would  suggest  its  cause  being  due  to 
some  micro-organism.  Letzerich  and  others  have  described  such  mici^o- 
organisms  in  the  sputum  of  patients  suffering  from  whooping  cough  ;  but  it  is 
doubtful  if  the  actual  specific  bacillus  has  been  isolated  from  the  numerous 
micro-organisms  found  in  the  secretions  of  the  mouth  and  fauces.  From 
the  observations  of  Von  Herfif  and  others  who  have  watched  the  larynx  with 
a  laryngoscope  during  a  paroxysm  of  coughing,  it  would  appear  that  a 
small  flake  of  mucus  secreted  from  the  posterior  wall  of  the  larynx  was  the 
excitant  of  the  spasm.  The  entire  larynx  and  trachea  was  in  a  condition 
of  catarrh,  the  greatest  irritability  being  in  the  inter-arytenoid  region  and  the 
under  part  of  the  glottis.  Some  believe  that  the  nasal  mucous  membrane 
rather  than  the  lower  respiratory  tract  is  the  seat  of  irritation,  and  that  it  is 
here  that  local  remedies  should  be  applied. 

No  characteristic  appearances  are  found  on  XSi&  post-mortem  XsthYo.;  the 
lesions  found  will  vary  according  to  the  mode,  of  death.  The  brain  is 
usually  congested,  especially  the  veins  ;  there  is  often  some  subarachnoid 
fluid  on  the  convexity  and  much  fluid  in  the  lateral  ventricles.  Various 
lesions  may  be  found  in  the  lungs,  such  as  injection  of  the  mucous  mem- 
brane of  the  larynx  and  bronchi,  with  excessive  secretion,  emphysema, 
collapse,  and  various  stages  of  broncho-pneumonia. 

Treatme7it. — The  most  important  part  of  treatment  consists  in  confining 
the  patients  to  well-aired  rooms  which  are  free  from  draughts  and  maintained 
at  an  equable  temperature.  Two  large,  rooms  should,  if  possible,  be  set 
apart  for  the  treatment,  the  one  occupied  being  maintained  at  a  temperature 
of  60°,  while  the  other  is  being  thoroughly  aired  or  disinfected,  the  latter 
being  again  Avarmed  before  the  patients  are  removed.  There  can  be  no  doubt 
that  the  attack  is  rendered  more  intense  and  protracted  by  rebreathing  the 
infection  as  well  as  by  a  fresh  catarrh  being  set  up.  Except  in  the  warmest 
weather,  the  patient  should  be  confined  to  his  rooms  in  the  house  the  whole 
time  the  disease  lasts,  as  long  as  any  '  whooping '  is  present,  and  as  long  as 


]V hooping  Cough  317 

any  rales  or  rhonchi  are  heard  in  the  chest.  Too  great  care  cannot  be 
exercised  here  ;  the  bronchial  tubes  and  lungs  remain  exceedingly  sensitive 
to  cold,  and  many  severe  attacks  of  plcuro-pneumonia  have  resulted  both  in 
old  and  young  from  a  chill  caught  at  outdoor  games  or  from  having  gone  to 
the  seaside  for  change  of  air.  Children  are  much  better  at  home  until 
well  over  the  attack,  not  only  for  the  sake  of  others  but  for  themselves  ;  and 
the  pleadings  of  the  friends  for  change  of  air  must  be  sternly  resisted  until 
six  weeks  at  least  from  the  commencement  of  whooping.  With  regard 
to  medicinal  treatment,  there  is  no  lack  of  remedies  which  have  been 
tried,  and  no  disease  has  been  more  ineffectually  though  diligently  drugged. 
It  is  c[uite  safe  to  say  that  no  specific  has  as  yet  been  discovered.  During 
the  catarrhal  stage,  when  the  cough  is  hard,  the  expectoration  scanty,  and 
there  is  fever,  the  best  remedies  include  small  doses  of  antimony,  ipecacuanha, 
liq.  amnion,  acetatis,  or  nitrate  of  potash.  At  night,  when  the  cough  is 
especially  troublesome,  hot  mustard  poultices  should  be  applied  to  the  chest, 
and  hot  demulcent  drinks,  such  as  black  currant  tea,  or  barley  water,  or 
lemonade  may  be  taken.  Beef  tea  is  often  of  service  for  the  night,  and 
a  dose  of  hot  brandy-and-water  will  sometimes  induce  sleep.  The  room 
should  be  kept  moist  with  hot  steam  if  there  is  much  bronchial  catarrh 
or  laryngitis.  In  the  spasmodic  stage,  when  the  secretion  is  free,  the  ex- 
pectorants should  be  stopped,  and  sedatives  and  small  doses  of  narcotics 
substituted.  At  this  stage  the  diffusion  of  carbolic  acid  vapour  through 
the  apartment  is  frequently  of  great  service  ;  this  may  be  done  by  vaporis- 
ing strong  carbolic  powder  in  one  of  Calvert's  carbolic  vaporisers  ;  it  is 
not  certain  how  this  acts  ;  no  doubt  to  some  extent  it  soothes  by  acting  as 
an  anaesthetic  to  the  fauces.  In  a  similar  way  cocaine  or  resorcin  may  be 
used  in  the  form  of  a  spray  or  mopped  on  to  the  fauces  with  a  brush  ;  but  the 
effect  is  usually  only  temporary,  as  the  anaesthesia  produced  by  cocaine  is 
too  short  to  be  of  much  service.  Internally  we  are  inclined  to  believe  that 
antipyrin,  antifebrin,  and  phenacetin  are  among  the  most  useful  remedies  ; 
from  two  to  eight  grains  of  the  former  being  given  every  four  hours,  according 
to  age,  and  half  this  dose  of  the  last  two.  (F.  53).  Of  other  drugs  at  this  period 
belladonna,  chloral,  bromides,  opium,  cannabis  indica,  quinine,  take  the  first 
place,  but  all  at  times  fail  to  give  any  appreciable  relief.  Tr.  belladonna  is 
best  given  in  small  doses  every  four  or  six  hours,  increasing  the  frequency 
rather  than  the  size  of  the  dose.  The  combination  of  belladonna  and 
cannabis  indica  is  a  favourite  one  ;  they  may  be  combined  as  in  F.  52. 

The  bromides  and  quinine  dissolved  in  syrup  of  lemons  with  syrup  of 
Santa  Yerba  is  also  a  good  combination.  Croton  chloral  is  highly  praised 
by  Dr.  Webb  ;  he  orders  a  drachm  of  this  drug  to  be  dissolved  in  two  ounces 
each  of  tr.  cardamomi  and  glycerine,  giving  half  a  teaspoonful  to  two  tea- 
spoonfuls  every  four  hours  to  children  of  one  to  ten  years.  Dr.  Ringer 
advises  tr.  lobeliae,  and  gives  doses  of  five  to  ten  minims  every  hour  even  to 
young  children.  Opium  is  of  all  drugs  the  most  certain  to  relieve  ;  but  it  is 
perhaps  best  reserved  to  be  given  in  one  dose  at  night  ;  one  to  five  drops 
of  nepenthe  or  half  to  two  grains  of  Dover's  powder  will  often  secure  a  fairly 
good  night.  The  bowels  should  be  carefully  attended  to,  and  a  laxative  will 
frequently  be  required.  Unless  the  secretion  is  very  copious,  poultices  or 
fomentations  in  this  stage  give  more  relief  than  do  liniments. 


3i8  The  Specific  Fevers 

In  the  later  stages,  when  the  secretion  is  copious  and  the  cough  less  and 
less  spasmodic  in  character,  nitric  acid,  alum,  quinine,  are  most  likely  to  be 
of  service.  Alum  may  be  given  with  some  sedative  as  conium  or  hyoscyamus, 
the  old  formula  of  Golding-Bird's  being  a  good  one  :  Alum.  gr.  j,  succi 
conii  lT\v,  syrup,  rhoeados  ITlx,  aq.  anethi  ad  5j  !  5j  every  four  hours. 
Of  external  applications  there  are  a  goodly  number  which  have  been  em- 
ployed with  varying  success.  Equal  parts  of  lin,  camph.  co.,  lih.  saponis, 
and  lin.  belladonnae,  used  cautiously  to  tender  skins,  make  a  good  stimu- 
lating liniment.  Some  have  great  faith  in  oil  of  amber,  as  in  the  following  : 
Ol.  succini  5ijj  tr.  opii  5ij'  ^p.  camiph.  _^ss,  ol.  amygdalae  gss.  The  hniment 
of  iodide  of  potassium  and  soap  is  useful.  .  The  diet  both  in  the  spasmodic 
and  catarrhal  stage  should  be  carefully  arranged,  and  is  difficult  on  account 
of  the  vomiting  so  frequently  present.  It  will  often  be  necessary  to  feed  little 
and  often  to  make  up  for  food  vomited.  The  complications,  such  as  broncho- 
pneumonia and  intestinal  catarrh,  must  be  treated  on  the  general  principles 
given  elsewhere. 

IVIuinps,  Parotitis, — Mumps  is  an  infectious  disease  which  is  apt  to 
prevail  in  epidemics  ;  sometimes  these  extend  over  wide  areas,  though  at 
other  times  cases  occur  and  there  is  little  tendency  to  spread.  We  have 
never  noticed  an  extensive  epidemic  in  hospital,  but  the  nurses  are  apt  to 
catch  the  disease  from  children  who  have  been  admitted  incubating  mumps, 
and  it  would  seem  that  close  contact,  perhaps  inhaling  the  affected  person's 
breath,  was  the  commonest  way  in  which  an  attack  was  contracted.  It 
sometimes  happens  that  there  is  no  spread  of  the  disease  in  the  ward  where 
the  affected  child  was,  but  cases  have  occurred  in  other  wards,  the  infection 
being  carried  by  a  nurse,  or  perhaps  by  a  nurse  who  has  herself  had  a  slight 
attack. 

Incubation. — According  to  Dr.  Dukes,  fourteen  to  twenty-five  days.  In 
some  cases  observed  by  us,  it  was  fourteen,  seventeen,  and  twenty-one  days 
respectively. 

Syiiiptoins  afid  Coterse. — Mumps  is  usually  a  mild  disease  attended  by 
discomfort  rather  than  serious  illness.  The  attack  usually  begins  with  chilli- 
ness, stiffness  about  the  jaws,  local  tenderness,  often  neuralgic  pains  ;  there 
is  often  no  fever,  sometimes  the  temperature  goes  up  suddenly  to  102°  or 
103°.  The  sweUing  is  at  first  one-sided,  involving"  the  region  of  the  parotid, 
which  is  prominent  and  tender  ;  deglutition  is  difficult  and  painful.  Both 
sides  are  usually  swollen  in  a  day  or  two,  and  the  patient  presents  a  cha- 
racteristic appearance.  The  fauces  and  tonsils  are  normal.  While  the 
parotids  are  usually  affected,  in  some  cases  the  swelling  is  entirely  confined 
to  the  sub-maxillary  sdlivary  glands  on  one  or  both  sides  ;  it  is  in  these 
cases  that  the  nature  of  the  attack  is  likely  to  be  overlooked.  The  attack 
lasts,  as  a  rule,  from  a  few  days  to  a  week.  Orchitis  occasionally  occurs  in 
boys  about  puberty.     Kemipleg-ia  has  been  known  to  follow  (Gowers). 

Diagnosis. — We  have  known  cases  of  mumps  sent  into  a  scarlet  fever 
ward  as  cases  of  scarlet  fever,  and  we  have  also  seen  a  case  of  tonsillitis  with 
enlarged  cervical  glands,  probably  scarlatinal,  which  was  diagnosed  as  mumps. 
In  all  cases  of  doubt  as  to  the  nature  of  the  external  swelling,  the  appearances 
presented  by  the  tonsils  should  be  decisive.  The  swelling  due  to  mumps  in 
the  majority  of  cases  corresponds    to  the    parotid    region,  the  swelling  of 


Mumps,  Parotitis-  Malarial  Fever  319 

cervical  glands  secondary  to  tonsillar  affections  is  at  the  angle  of  the  jaw 
or  just  behind  it.  There  is  rarely  much  fever  or  illness  with  mumps;  in 
di])htheria  or  scarlet  fever,  where  there  is  much  external  swelling  or  cellulitis, 
the  child  is  evidently  gravely  ill,  and  if  a  satisfactory  view  of  the  fauces  can 
be  obtained,  they  will  be  seen  to  be  swollen,  a^dematous,  and  perhaps  covered 
with  exudation.  In  adenitis,  attended  by  fever,  it  is  the  lymphatic  glands 
rather  than  the  parotid  which  are  affected.  In  spite,  however,  of  these  dis- 
tinctions, difficult  and  doubtful  cases  may  occur.' 

T?'eat?nent.—'Hot  much  is  required  except  hot  fomentations  or  belladonna 
liniment  to  the  parotid  regions,  and  a  saline  followed  by  a  tonic.  Three  or 
four  weeks,  according  to  the  severity  of  the  case,  should  elapse  before  the 
patient  returns  to  school  or  mixes  with  his  fellows. 

IVIalarial  Pever. — Children  who  live  in  malarial  districts  suffer  from 
malarial  attacks  as  frequently  as  do  adults  ;  indeed,  according  to  Holt,  they 
are  peculiarly  susceptible.  In  this  country  many  opportunities  do  not  occur 
of  seeing  the  disease  in  its  early  stages  ;  the  cases  which  mostly  come 
under  observation  are  those  which  are  chronic  ;  having  acquired  the  disease 
abroad  and  having  been  invalided  home.  In  these  cases  marked  anaemia 
with  enlarged  spleen,  and  perhaps  intermittent  fever,  form  the  c  j  n  n  )  u ; 
symptoms.  The  anaemia  is  frequently  profound,  and  the  spleen  attains  to 
an  enormous  size.  Nephritis  as  a  sequela  of  aguish  attacks  is  sometimes 
seen  in  this  country.  Such  a  case  we  saw  with  Dr.  Massiah,  the  attack 
having  been  contracted  in  Brazil  ;  there  was  marked  ansemia,  enlarged 
spleen,  the  urine  was  highly  albuminous,  and  contained  fatty  and  fibrinous 
casts.  According  to  Lewis  Smith,  intermittent  fever  when  it  affects  those 
over  2>h  years  differs  little  from  the  adult  form,  while  below  that  age  it  presents 
some  peculiarities.  Malarial  fever  may  be  hereditary,  being  derived  from 
the  mother.  In  one  case,  recorded  by  Lewis  Smith,  an  infant  showed  dis- 
tinct symptoms  a  week  after  birth  ;  the  mother  had  suffered  from  tertian 
ague  at  intervals  during  the  two  years  prior  to  her  confinement.  In  the 
infant  the  type  is  quotidian,  rarely  tertian  ;  there  are  three  stages  presented 
by  an  attack  :  the  second  or  febrile  is  well  marked,  the  temperature  rising  to 
104°  to  106°  ;  the  first  and  third  less  so.  The  spleen  soon  enlarges,  and 
after  a  week  or  two,  if  the  attack  continues,  there  is  marked  ancemia.  The 
enlargement  of  the  spleen  fails  to  take  place  in  some  of  the  cases.  Dr. 
Emmett  Holt,  of  New  York,  in  making  an  analysis  of  the  symptoms  of  184 
cases  of  malaria  in  children,  has  pointed  out  how  much  more  insidious  the 
invasion  of  the  disease  is  in  children  than  in  adults,  and  consequently  there 
is  more  liability  to  overlook  it  and  attribute  the  symptoms  to  other  causes. 
Even  the  periodicity  of  the  recurrence  may  not  be  regular,  which  would 
still  more  throw  the  physician  off  his  guard.  In  his  cases  with  a  gradual 
invasion  he  noted  anaemia,  frontal  headache,  constipated  bowels,  muscular 
weakness,  vomiting,  furred  tongue,  drowsiness,  and  epigastric  pains  ;  these 
symptoms  usually  recurring  in  the  afternoon.  The  spleen  was  enlarged,  but 
there  were  exceptions  to  this.  The  fever  noticed  by  this  author  assumed  three 
types  :  the  first,  in  which  the  fever  remained  high  for  twenty-four  to  seventy- 
two  hours,  when  a  marked  remission  took  place,  the  temperature  then  assum- 

'  Suppuration  in  a  parotid  gland  may  take  place  in  enteric  or  pyasmia  ;  but  this  can 
hardly  be  mistaken  for  mumps. 


320  The  Specific  Fevers 

ing  a  remittent  type  ;  secondly,  the  fever  is  at  first  slight  and  only  present 
at  one  period  of  the  twenty-four  hours,  but  gradually  increases  in  intensity 
and  assumes  a  remittent  type  ;  thirdly,  assuming  a  distinctly  remittent 
or  intermittent  type  from  the  outset.  Cerebral  symptoms  are  common  ; 
there  are  frontal  headache,  drowsiness,  and  apathy,  occasionally  convul- 
sions ;  pains  in  various  parts  of  the  body  ;  various  spasmodic  disorders, 
as  torticollis  and  motor  paralysis,  are  less  common,  but  sometimes  take  the 
form  of  paraplegia.  Dr.  Holt  has  also  pointed  out  that  the  malarial  poison 
may  complicate  and  modify  other  diseases  ;  of  these  bronchitis  and  pul- 
monary congestion  are  common,  the  latter  closely  resembling  pneumonia  in 
the  onset,  but  subsiding  in  a  few  hours,  to  come  on  again  in  the  course  of 
twenty-four  hours.  Spasmodic  asthma  of  malarial  origin  may  occur.  Various 
gastro-intestinal  disorders,  as  vomiting  and  diarrhoea,  occur  periodically  at  a 
certain  time  daily.  The  diagnosis  in  these  cases  depends  upon  :  (i)  Perio- 
dicity of  the  symptoms ;  (2)  the  co-existence  of  splenic  enlargement  ; 
(3)  failure  of  the  usual  remedies  to  relieve  ;  (4)  their  prompt  disappearance 
under  the  use  of  antiperiodics. 

Treatment. — The  treatment  consists,  as  in  adults,  in  the  administration  of 
antiperiodics,  such  as  quinine,  cinchonine,  and  arsenic. 


321 


CHAPTER    X\T 

DISEASES    OF   THE    RESPIRATORY    APPARATUS 

The  Thorax  In  Infancy  and  Childhood. — It  is  necessary  when  exa- 
mining the  chest  of  an  infant  or  child  for  the  first  time  to  have  it  completely 
bare,  so  that  a  thorough  examination  can  be  made,  the  infant  lying  in  its  cot 
or  on  its  mother's  lap  ;  care  must,  of  course,  be  taken  to  have  the  room  suffi- 
ciently warm,  as  infants  readily  take  cold  when  a  large  surface  of  the  skin 
is  exposed,  and  they  are  very  sensitive  to  draughts. 

On  inspection  it  will  be  noticed,  yJ'rj/'/y,  that  an  infant's  chest  is  deeper 
than  an  adult's,  or,  in  other  words,  the  antei'o-posterior  diameter  more  nearly 
approaches  the  transverse,  the  I'atio  being  1-2  in  an  infant,  1-2^  during  child- 
hood, and  1-3  or  3^  in  adults  ;  the  horizontal  section  is  thus  more  circular  in 
form  during  infancy  than  in  later  life.  Secondly,  the  angle  which  the  costal 
cartilages  make  with  the  sternum  is  lai'ger  in  children  than  in  adults,  that  is, 
the  lower  part  of  the  thoracic  cage  is  widened  out  more  ;  this  may  be  in  part 
due  to  or  accentuated  by  the  abdominal  viscera  occupying  a  relatively  larger 
space  and  pressing  the  diaphragm  upwards.  This  is  seen  in  an  exaggerated 
form  in  children  who  have  enlarged  livers  and  constant  gaseous  distension 
of  the  stomach  and  intestines.  Any  acquired  deformity  should  be  carefully 
noted  ;  various  rickety  deformities  may  be  present — one  side  of  the  chest  may 
be  contracted  from  an  old  pleurisy  or  empyema,  or  the  left  chest  may  be 
bulged  outwards  by  an  hypertrophied  heart  or  distended  pericardium. 

The  way  in  which  the  child  breathes  should  be  carefully  noticed.  There 
may  be  a  '  crowing'  inspiration  as  in  laryngismus,  or  it,  may  be  stridulous, 
there  being  an  evident  obstruction  both  to  filling  and  also  emptying  the 
chest.  The  cough  may  have  a  metallic  or  clanging  ring  :  the  rhythm  of  the 
respiratory  movements  may  be  altered,  as  in  meningitis. 

Note  inust  also  be  made  of  the  frequency  and  character  of  the  respiratory 
movements,  whether  deep  or  shallow,  whether  one  side  moves  more  freely 
than  the  other,  or  if  there  is  any  sinking  in  of  the  epigastrium  or  intercostal 
spaces  and  ribs  during  inspiration.  It  should  be  borne  in  mind  that  mere 
frequency  of  respirations  does  not  necessarily  mean  any  respiratory  disease, 
but  may  be  due  to  rapidity  of  the  heart's  action  accompanying  high  fever  or 
cardiac  feebleness.  Note  also  if  there  is  any  paralysis  of  the  diaphragm  or 
intercostals.     The  position  of  the  cardiac  impulse  should  be  determined. 

After  inspection  it  is  usual  to  percuss  the  chest,  placing  one  finger  of  the 
left  hand  against  the  chest  wall  and  striking  it  with  more  or  less  force 
with  the  middle  finger  or  forefinger  of  the  right  hand,  taking  care  that  the 
child  lies  or  sits  up  straight,  for  if  the  body  be  twisted,  so  that  one  side 

Y 


322  Diseases  of  the  Respiratory  Apparatus 

bulges  out  more  than  the  other,  a  fallacious  hyper  or  impaired  resonance  may 
be  produced.  All  the  regions  of  the  chest  must  be  carefully  examined  in  turn. 
Too  much  stress  should  not  be  laid  on  a  slightly  impaired  resonance,  espe- 
cially if  the  child  is  crying,  unless  the  result  of  auscultation  corresponds, 
and  a  subsequent  examination  confirms  the  result.  A  typical  '  cracked-pot ' 
sound  is  readily  elicited  in  an  infant  on  account  of  the  yielding  nature  of  the 
chest  walls  quite  apart  from  the  presence  of  cavities  or  any  lung  lesion. 
Careful  note  must  be  made  of  any  spot  where  there  is  dulness  or  impaired 
resonance  or  hyper-resonance  denoting  emphysema,  but  bearing  in  mind 
that  at  times  a  'boxy 'note  is  elicited  over  lung  in  an  early  stage  of 
pneumonia  or  acute  congestion.  It  must  not  be  forgotten  in  examining 
the  chest  that  the  diaphragm  usually  takes  a  higher  position  in  children 
than  in  adults,  especially  when  the  stomach  and  intestines  are  distended 
with  gas. 

In  auscultation  the  ear  may  be  placed  directly  against  the  chest  wall,  or 
(what  is  much  more  convenient)  a  binaural  stethoscope  with  a  small  chest 
piece  may  be  used.  All  parts  of  the  chest  should  be  carefully  examined, 
noting  the  character  of  the  breathing,  whether  the  air  is  entering  every 
part  of  the  lungs  equally,  or  whether  the  air  is  not  entering^  one  part  freely 
while  other  parts  are  being  overworked.  Weak  breathing  may  be  due  to  an 
early  stage  of  pneumonia,  effusion  of  fluid,  collapse  of  lung,  compression  of  a 
bronchus,  or  a  pneumo-thorax. 

'  Puerile '  or  harsh  breathing  is  due  to  a  portion  of  lung  being  over- 
worked ;  it  is  never  safe  to  accept  it  as  a  sign  of  a  lesion  in  the  lung,  as 
at  first  a  student  is  inclined  to  do,  and,  moreover,  the  breath  sounds  may 
appear  loud  and  harsh  to  an  ear  accustomed  only  to  adults.  It  is  not  uncom- 
mon in  young  children  to  note  on  one  occasion  that  the  breathing  is  weak  or 
almost  absent  at  one  base  and  loud  elsewhere,  whereas  after  a  fit  of  crying, 
or  the  next  day,  the  weak  breathing  has  completely  disappeared  ;  in  these 
cases  a  bronchus  with  its  branches  has  been  temporarily  plugged  with 
mucus,  which  has  become  displaced  by  coughing.  Bronchial  breathing  is 
present  in  consolidation  of  the  lung  from  pneumonia  or  tubercular  infiltra- 
tion, but  it  is  also  present  in  the  majority  of  cases  in  effusion  of  fluid,  though 
in  this  case  it  is  usually  weak  and  distant  instead  of  being  intense  and  blowing. 
Cavernous  or  amphoric  breathing  is  not  often  heard,  as  cavities  of  any  size 
are  rare  in  young  children.  Among  the  adventitious  sounds,  fine  crepitation 
is  rarely  heard  in  the  early  stages  of  pneumonia,  the  rales  being  mostly  of 
medium  size  ;  they  may  be  '  consonant'  or  '  ringing'  in  character  when  con- 
veyed to  the  ear  through  solid  lung,  or  subcrepitant  and  ill  defined  when  the 
secretion  is  thick  and  they  have  to  pass  through  normal  lung  to  reach  the 
ear.  Vocal  resonance,  or  fremitus,  often  gives  no  definite  result  in  girls  or 
young  children,  though  when  the  child  is  crying  violently  the  increased  reson- 
ance of  the  voice  heard  over  a  base  or  apex  may  be  of  diagnostic  importance. 
It  is  needless  to  add  that  the  physical  examination  of  young  children  is  often 
beset  with  difficulties  on  account  of  their  restlessness  or  fright,  and  the 
examiner  may  have  his  patience  often  sorely  tried,  and  perhaps  may  fail  to 
obtain  a  satisfactory  examination  from  this  cause. 

Cong-enital  Iiaryn^eal  Stridor. —  It  is  not  uncommon  to  meet  with  in- 
fants, who  from  their  birth  have  made  a  peculiar  stridulous  sound  during 


Laryngismus  323 

respiration,  more  especially  during  inspiration.  In  most  cases  this  noisy 
respiration  lasts  for  some  months,  perhaps  getting  worse  for  a  while,  and  then 
gradually  improving,  so  that  before  the  middle  of  the  second  year  is  reached 
it  has  entirely  disappeared.     It  is  not  dangerous  to  life,  as  is  true  laryngismus. 

The  infants  affected  in  this  way  are  usually  perfectly  strong,  and  their 
health  does  not  appear  to  suffer.  The  stridor  in  some  cases  is  continuous, 
but  worse  when  the  infant  is  excited  and  breathes  irregularly,  and  less  marked 
or  absent  during  sleep  or  when  it  is  quiet.  It  does  not  become  cyanotic,  but 
the  chest  wall  is  frequently  sucked  in  during  inspiration  and  the  chest  tends 
to  become  constricted  where  the  diaphragm  is  attached.  Inspiration  is 
laboured  and  noisy,  expiration  is  comparatively  easy.  In  some  cases  when 
excited  and  crying  the  hands  are  clenched  and  the  thumb  turned  in  during 
inspiration.  Dr.  J.  Thomson  describes  the  stridor  as  follows  :  '  Inspiration 
l)egins  with  a  croaking  noise  and  ends  in  a  high-pitched  crow,  which  two  of 
the  mothers  described  as  being  just  like  a  hen.'  This  author  is  inclined  to 
regard  this  condition  as  a  development  neurosis,  like  stammering.  On  the 
other  hand,  Sutherland  and  Lack,  who  examined  six  cases,  came  to  the  con- 
clusion that  the  stridor  was  not  produced  by  spasm  of  the  glottis,  but  at  the 
upper  aperture  of  the  larynx.  The  aryto-epiglotidean  folds  which  form  the 
lateral  walls  of  the  upper  aperture  turned  in  during  inspiration  and  reduced 
the  aperture  to  a  mere  slit,  during  expiration  they  opened  out  again.  It  is 
this  valve-like  action  of  the  upper  aperture  which  produces  the  stridor.  The 
action  of  the  cords  was  apparently  normal.  If  this  view  is  correct  the  con- 
dition must  be  looked  upon  as  a  malformation  rather  than  as  a  neurosis. 
Post-nasal  adenoids  were  absent  in  the  cases  examined.  This  condition  is 
not  affected  by  drugs. 

In  some  few  cases  we  have  noted,  in  addition  to  a  certain  amount  of  noisy 
respiration  in  infants,  there  is  a  tendency  to  choke  when  drinking,  some  of 
the  fluid  entering  the  larynx  by  accident.  This  condition,  though  alarming 
to  the  friends,  does  not  appear  to  be  dangerous,  and  gradually  improves  as 
the  infant  grows  older.  Thus  in  an  infant  of  thirteen  months  there  is  constant 
choking  during  the  second  act  of  deglutition  when  fluids  are  being  swallowed. 
Some  fluid  goes  the  wrong  way,  then  there  is  choking  and  spluttering.  It 
could  swallow  '  sops  '  all  right.  This  difficulty  comes  and  goes,  and  is  worse 
when  the  infant  is  excited.  There  is  apparently  some  want  of  co-ordination 
of  the  muscles  of  deglutition. 

Xiaryng-isiuus.     Spasm  of  tbe   Glottis.      '  Child  Cro\(ring' ' 

The  term  laryngismus  is  applied  to  a  peculiar  form  of  laryngo-respiratory 
spasm  which  occurs  almost  exclusively  in  rickety  infants.  In  laryngismus 
there  is  no  lesion  of  the  larynx,  or  only  in  a  small  minority  of  cases  is  there  a 
laryngeal  catarrh  ;  it  is  usually  a  pure  neurosis,  and  it  is  only  for  the  sake 
of  contrasting  it  with  other  forms  of  laryngeal  troubles  that  it  is  placed  in  this 
section  rather  than  among  the  convulsive  disorders,  to  which  it  more  properly 
belongs. 

In  by  far  the  majority  of  cases  the  symptoms  of  rickets  and  chronic 
indigestion  are  present,  but  we  must  not  in  all  the  cases  expect  to  find  marked 
enlargement  of  the   epiphyses,   especially   in  infants  of  a  few   months   old. 

V  2 


324  Diseases  of  the  Respiratory  Apparatus 

Sometimes  cranio-tabes  may  be  detected  ;  usually  there  is  some  beading"  of 
the  ribs  and  recession  of  the  chest  walls  during  inspiration.  In  the  majority 
there  is  marked  gaseous  distension  of  the  small  intestines  and  pale  pasty 
stools. 

The  characteristic  feature  of  the  attack  is  a  sudden  '  holding  of  the 
breath '  for  a  few  seconds  ;  then  the  glottis  is  burst  open,  the  air  rushing  in 
with  a  stridulous  sound  or  in  a  series  of  short  '  chinks,'  but  in  many  cases 
there  is  no  abnormal  sound,  the  attack  consisting  entirely  of  holding  the 
breath.  The  seizure  closely  resembles,  only  in  an  exaggerated  form,  the 
'  catch  in  the  breath '  which  takes  place  as  a  preliminary  to  a  good  fit  of 
crying,  or,  as  Gay  points  out,  of  rage  or  bad  temper.  The  condition  seems 
to  be  as  if  the  expiratory  respiratory  centre  discharges  for  a  few  seconds  an 
excessive  quantity  of  nerve  force,  producing  a  spasm  of  the  glottis  and  of  the 
muscles  of  expiration,  while  the  more  powerful  inspiratory  centre,  as  it  is  more 
and  more  stimulated  by  the  increasing  venosity  of  the  blood,  strives,  as  it 
were,  for  mastery,  and  at  length,  when  it  succeeds,  the  glottis  is  burst  open, 
and  air  rushes  in  through  the  narrow  chink.  In  a  severe  attack  not  only  is 
the  glottis  closed  by  the  adductors  of  the  cords,  but  the  epiglottis  may  be 
felt  by  the  finger  to  be  spasmodically  applied  to  the  superior  aperture  of  the 
larynx,  and  the  respiratory  muscles  are  in  a  state  of  spasm. 

Semon  and  Horsley  have  shown  that  the  expiratory  respiration  centre  is 
situated  in  the  monkey  in  the  cortex,  'just  posterior  to  the  lower  end  of  the 
prascentral  sulcus  at  the  base  of  the  third  frontal  convolution.'  Stimulation 
of  this  region  produces  adduction  of  the  vocal  cords,  and  if  the  excitation  be 
powerful  enough,  spasm  of  the  muscles  of  the  face,  neck,  and  upper  limbs. 
The  same  observers  failed  to  discover  any  inspiratory  cortex  centre,  but 
found  that  excitation  of  the  accessory  nucleus  in  the  medulla  oblongata 
evoked  abduction  of  the  cords.  In  rickets  the  nerve  centres  are  in  an 
unstable  condition,  and  liable  to  liberate  nerve  force  on  the  slightest  provo- 
cation. In  some  cases  many  of  the  cortex  centres  discharge,  and  a  general 
convulsion  is  produced  ;  in  other  cases  it  may  be,  at  first  at  any  rate,  the 
expiratory  respiration  centre  only,  and  a  spasm  of  the  glottis  is  produced. 

The  exciting  causes  are  probably  many.  The  commonest  is  some  emo- 
tional disturbance  :  a  fit  of  crying  or  of  anger  may  quickly  pass  into  an 
attack  ;  fright  or  a  sudden  stall  may  bring  one  on.  The  act  of  swallowing 
seems  also  sometimes  to  give  rise  to  an  attack.  Dentition,  irritation  of  the 
mucous  membrane  of  the  pharynx  and  larynx,  nasal  adenoids,  constipation, 
may  perhaps  act  as  exciting  causes.  In  a  patient  of  ours  the  attacks  were 
apparently  worse  during  the  time  it  was  suffering  from  some  aphthous  ulcers 
on  the  soft  palate.  We  have  also  seen  cases  which  were  associated  with 
laryngeal  and  bronchial  catarrh.  We  are  not  inclined  to  attach  much 
importance  to  an  enlarged  thymus,  swollen  bronchial  glands,  or  cranio-tabes 
as  exciting  causes. 

Symptoms. — In  the  milder  cases,  which  are  the  most  common,  the  child's 
inspiratory  movements  are  accompanied  by  a  slight  'crowing  sound,'  which 
does  not  appear  to  distress  it,  and  which  passes  off  during  sleep.  Some- 
times the  crowing  will  last  for  days,  and  pass  off  again  for  some  time.  In 
some  few  cases  the  stridor  is  present  during  sleep  as  well  as  during  the  time 
the  child  is  awake.    In  the  most  severe  cases  the  attacks  come  on  at  frequent 


Laryngis7n  us  325 

intervals,  and  arc  distressing"  in  the  extreme  ;  without  warning,  the  infant  is 
seen  to  screw  up  its  face  as  if  for  a  crying  fit,  it  holds  its  breath,  no  air  enters, 
and  the  respiratory  muscles  are  rigid  and  motionless,  the  veins  on  the  face 
and  scalp  become  distended  with  venous  blood,  the  face  and  lips  become 
blue,  or  of  a  dusky  tint  ;  then  after  ten  or  more  seconds  the  obstruction  to 
the  air  entering  the  lungs  is  overcome,  and  air  rushes  into  the  now  open 
glottis.  In  some  cases  we  have  noted  that  while  at  first  the  respiratory 
muscles  are  quite  motionless,  in  others,  after  the  obstruction  has  lasted  some 
seconds,  the  diaphragm  begins  to  work  spasmodically,  and  will  often  succeed 
in  forcing  the  glottis,  so  that  for  a  few  seconds  air  is  admitted  at  short  in- 
tervals into  the  chest  ;  then  for  a  time  the  attack  is  over,  but  may  be  shortly 
followed  by  another. 

These  seizures,  especially  the  more  severe  ones,  are  accompanied  by 
clonic  spasms  of  the  limbs  ;  sometimes  we  have  seen  in  these  attacks  the 
infant  throw  his  hands  up  like  a  drowning  man,  and  then,  after  the  laryngeal 
spasm  is  over,  the  nerve  discharge  passes  into  the  limbs,  and  the  hands 
become  set,  as  in  tetany,  with  the  thumbs  turned  in,  and  the  feet  in  a  position 
of  equino-varus. 

These  attacks  may  come  on  at  all  times  of  the  day  or  night,  and  on  very 
slight  provocation.  We  have  already  referred  to  the  most  common  exciting 
causes  ;  the  most  important,  perhaps,  is  some  emotional  disturbance.  One 
of  these  seizures,  as  we  have  already  pointed  out,  is  very  much  like  what 
takes  place  in  the  early  stages  of  a  fit  of  crying  ;  the  facial  muscles  are  con- 
tracted, the  mouth  is  open,  the  breath  is  held,  the  air  enters  the  chest  spas- 
modically by  the  contraction  of  the  diaphragm.  Herbert  Spencer  remarks 
that  an  '  overflow  of  nerve  force,  undirected  by  any  motive,  will  manifestly 
take  the  most  habitual  routes  ;  and  if  these  do  not  suffice,  will  next  overflow 
into  the  less  habitual  ones.'  We  can  easily  understand  on  this  principle  that 
a  discharge  of  nerve  force  from  unstable  nervous  centres  may  take  the  routes 
which  in  infants  produces  a  good  cry,  and  may  overflow  into  the  muscles  of  ■ 
the  extremities,  producing  a  spasmodic  condition,  i.e.  '  tetany.' 

One  point  we  must  not  forget  to  emphasise,  and  that  is,  that  many  of  the 
most  severe  seizures  are  not  accompanied,  or  rather  followed,  by  a  definite 
crowing  sound.  It  is  really  the  less  severe  ones  in  which  the  crowing  in- 
spiration fs  best  marked  ;  the  danger  necessarily  depends  more  upon  the 
length  of  time  during  which  the  breath  is  forcibly  held,  than  upon  the  manner 
in  which  the  air  again  enters.  In  many  of  the  worst  cases  it  is  admitted 
spasmodically  in  sobs,  and  not  in  a  long-drawn  crow. 

Children  who  suffer  from  laryngismus  are  not  only  rickety,  but  are  nearly 
always  dyspeptic.  There  is  often  a  difficulty  in  digesting  cow's  milk,  the 
stools  contain  much  undigested  curd,  and  there  is  chronic  distension  of  the 
bowels.  They  are  not  infrequently  well  nourished,  as  far  as  fat  goes,  but 
their  muscles  are  poorly  developed.  It  is  unnecessary  to  say  that  it  is 
artificially  fed  infants  who  are  the  chief  sufferers  from  laryngismus.  It  seems 
very  likely  the  unstable  condition  of  the  nerve  centres  are  due  to  toxine  poison- 
ing, the  toxine  being  absorbed  from  the  intestinal  contents.  The  following 
case  illustrates  some  of  the  points  we  have  referred  to  : 

Lni-ytigismus  ;  Recovery. — S.  H. ,  aged  lo  months  ;  admitted  Februar}'  28.  Mother  states 
lie  has  never  been  strong,  has  had  a  '  croupy  cough  '  since  14  days  old.     For  the  last  few 


326 


Diseases  of  the  Respiratory  Apparatus 


weeks  has  had  many  choking  fits,  sometimes  as  many  as  twenty  in  one  day.  Weight, 
9  lb.  14  oz.  He  is  small  for  his  age  and  cannot  sit  up  ;  he  has  no  teeth,  fontanelles 
widely  open  and  tense  ;  no  cranio-tabes  ;  some  recession  of  the  chest  walls  during  inspira- 
tion ;  no  marked  beading  of  the  ribs.  When  disturbed  he  makes  a  crowing  sound  with 
inspiration.  During  this  time  there  is  marked  indrawing  of  the  chest  wall,  lasting  for  a 
few  moments.  At  other  times  the  breath  is  held  tightly  for  a  few  seconds  till  he  becomes 
blue  in  the  face.  He  was  ordered  milk,  half  a  pint,  and  whey,  one  pint  and  a  half  daily, 
and  some  rhubarb  and  soda.  March  2. — Has  had  many  attacks  of  'crowing,'  and 
between  the  attacks  there  seems  to  be  more  or  less  constant  spasm.  March  4. — Ordered 
tr.  belladonnas  niiv,  pot.  bromidi  gr.  ijss,  om.  4tis  hor.  He  had  six  attacks  yesterday  ; 
no  general  convulsions.  From  this  date  he  began  to  improve,  the  attacks  becoming  less. 
He  went  home  on  March  21  (weight,  10  lb.  i  oz.),  having  had  no  attacks  for  ten  da)'s  or 
more. 

Spasm  of  the  glottis  is  sometimes  the  cause  of  death  in  cases  where  the 
obstruction  is  not  complete,  as  in  the  following  case.  A  boy  of  i  year  old 
had  difficulty  in  breathing  from  birth,  was  seized  with  a  bad  attack,  and  was 
admitted  to  hospital  ;  there  was  undoubted  obstruction  to  inspiration  and 
much  recession  of  the  chest  walls,  necessitating'  tracheotomy,  which  was 
followed  by  much  relief  Death  followed  five  hours  later  without  apparent 
cause.  At  the  post-mortem  there  were  no  signs  of  rickets  ;  there  was  slight 
congestion  of  the  larynx  and  the  thymus  gland ;  all  the  other  organs  were 
healthy.  Sudden  death  from  spasm  of  the  glottis  occasionally  occurs  in 
cases  of  tuberculosis  with  enlarged  and  caseous  mediastinal  glands. 

Diagnosis. — The  following  table  gives  the  chief  points  : 


Lciryngisvms  :  Spasm  of  the 
Glottis 

Occurs  in  rickety  children 
under  18  months  of  age. 

No  fever,  and  no  coryza  oi' 
laryngeal  catarrh. 

Occurs  at  any  period  of  the 
24  hours,  and  often  many 
times. 

No  cough,  inspirations  are 
stridulous. 

Contractions  of  the  limbs, 
or  general  convulsions, 
not  uncommon. 

The  attack  lasts  a  few  se- 
conds, and  frequently  re- 
curs. 

Occasionally  fatal. 


Spasmodic  Laryngitis 
{False  Croup) 

Rarel)'  occurs  under  2  years 
of  age,  commonest  2-7 
years. 

Slight  fever,  mostly  coryza 
and  laryngeal  catarrh. 

The  attack  occurs  at  night. 


Metallic  cough,  stridulous 
respiration,  variable  dys- 
pnoea. 

Convulsions  rare. 


Attack    passes    off    m    the 
course  of  an  hour  or  two. 


Rarel}'  fatal. 


Membranous  Croup 

Occurs  at  all  ages  during 
childhood. 

Variable  amount  of  fever, 
and  perhaps  some  diph- 
theria of  the  fauces. 

Mostly  worse  at  night. 


Metallic  cough,  stridulous 
respiration,  progressive 
dyspnoea. 

Convulsions  rare. 


Becomes  steadily  worse, 
though  variations  occur 
in  its  progress. 

Very  often  fatal. 


'gnosis. — The  great  majority  of  infants  who  suffer  from  '  child  crowing ' 
recover  ;  the  prognosis,  however,  must  always  be  a  guarded  one,  and  as  long 
as  there  is  any  tendency  to  spasm  of  the  glottis  the  child  cannot  be  regarded 
as  out  of  danger.  A  '  crowing '  child  may  at  any  time  have  general  convul- 
sions and  die  in  a  few  moments.  Improvement  in  the  child's  general  condi- 
tion, and  especially  of  its  digestive  powers,  quickly  leads  to  an  improvement 


LaryngisviMs — Spasmodic  Laryngitis  327 

in  the  '  crowing  ; '  this  wc  ha\e  noticed  in  several  cases  which  rapidly  im- 
proved under  the  careful  feeding  and  attention  in  the  hospital,  but  which 
quickly  relapsed  again  when  they  were  discharged.  An  attack  of  bronchitis 
or  broncho-pneumonia  is  very  likely  to  prove  fatal  in  a  child  subject  to 
laryngismus. 

Treatment. — During  the  spasmodic  stage  when  the  breath  is  being  held, 
every  effort  must  be  directed  towards  exciting  reflexly  the  inspiratory  respira- 
tory centre.  A  sponge  well  wetted  with  cold  water  may  be  dashed  into  the 
face  ;  patting  on  the  back,  or  a  vigorous  shake,  will  sometimes  be  successful. 
It  is  useful  to  have  a  hand  fan  within  reach,  and  use  it  vigorously  during  an 
attack  to  fan  the  face. 

We  have  found  that  hooking  back  the  epiglottis  with  the  forefinger  has 
been  followed  by  an  inspiration.  In  one  of  our  own  cases  a  child  who  was 
subject  to  these  attacks  had  a  severe  seizure  while  under  chloroform  for  the 
removal  of  post-nasal  adenoids,  and  his  life  was  only  saved  by  the  rapid 
performance  of  tracheotomy.  In  such  cases  a  catheter  passed  into  the 
larynx  would  suffice  to  insure  the  entry  of  a  small  quantity  of  air. 

The  fii"st  indication  for  treatment  is  to  give  a  dose  of  calomel  gr.  k — gr-  i, 
to  act  on  the  bowels  and  clear  away  all  decomposing  milk  foods.  The  most 
useful  medicines  for  temporary  use  to  keep  the  attacks  in  check  are  chloral, 
bromide,  and  minute  doses  of  morphia.  We  should  only  give  these  drugs  in 
the  severe  forms  of  spasms  in  order  to  soothe  or  render  less  irritable  the 
unstable  state  of  the  nervous  system.  Five  grains  of  bromide  with  two  and 
a  half  of  chloral  may  be  given  to  an  infant  of  nine  months,  and  repeated  every 
six  hours.  A  drop  of  liq.  morphije  may  be  given  every  six  hours,  its  effect 
being  carefully  watched. 

The  most  important  part  of  the  treatment  is  with  regard  to  the  diet  and 
surroundings  of  the  child.  It  is  of  the  greatest  importance  that  it  should 
get  fresh  air.  A  steam  tent  or  hot  close  room  is  the  worst  possible  place 
for  an  infant  suffering  from  laryngismus.  A  change  away  to  the  seaside  often 
works  wonders,  by  improving  the  infant's  digestive  powers  and  general  health. 
A  food  or  foods  must  be  found  and  given  in  quantities  which  the  child  can 
digest.  It  will  probably  be  found  that  the  child  is  taking  more  milk  than  it 
can  digest,  and  is  passing  large  pasty  stools.  The  amount  of  milk  must  be 
diminished.  Peptonised  foods,  cream  mixtures,  thin  oatmeal  gruel,  beef  juice, 
beef  tea  with  vegetables,  all  have  their  value  in  these  cases,  if  given  in 
suitable  quantities  according  to  the  child's  digestive  powers.  Medicines 
which  assist  the  digestion  and  regulate  the  bowels  are  often  necessary  ; 
extract  of  malt,  rhubarb  and  soda,  acids  and  pepsine,  and,  above  all,  cod  liver 
oil,  when  it  can  be  taken  and  digested.  Constipation  must  be  removed.  If 
a  child  has  laryngismus  and  post-nasal  adenoids,  is  it  safe  to  operate  ?  We 
have  several  times  operated  with  great  advantage  ;  but  it  is  necessary  to  be 
on  the  look-out  for  spasm  of  the  glottis.  Intubation  may  be  performed  or  a 
catheter  passed  into  the  trachea,  if  necessary,  and  artificial  respiration 
performed. 

Spasmodic  ]baryiigltis.     Catarrhal  Spasm.     False  Croup 

This  affection  differs  from  the  last  described  in  that  it  consists  in  a  sudden 
but  not  complete  stenosis  of  the  glottis  associated  with  a  laryngeal  or  pharyn- 


328  Diseases  of  the  Respiratory  Apparatus 

geal  catarrh.  A  child,  usually  above  2  or  3  years  of  age,  goes  to  bed 
apparently  well,  or  there  may  be  a  slight  hoarseness  or  cold  in  the  head  ; 
after  a  few  hours'  sleep  he  is  suddenly  awakened  with  alarming  symptoms  of 
larjmgeal  obstruction.  There  is  a  loud  metallic  cough,  stridulous  respiration, 
more  especially  with  inspiration,  the  dyspnoea  and  distress  are  very  great, 
there  is  recession  of  the  chest  walls,  and  all  the  accessory  muscles  are  called 
into  requisition.  The  orthopnoea  and  distress  are  so  great  that  death  seems 
imminent.  In  the  course  of  a  few  minutes,  probably  before  the  arrival  of 
medical  assistance,  which  is  hastily  summoned,  the  laryngeal  obstruction 
has  ceased,  and  the  child,  tired  out  by  its  unwonted  exertions,  falls  into  a 
quiet  sleep.  The  symptoms  of  a  catarrh  or  tracheitis  persist  for  some  days, 
perhaps  with  some  clanging  cough  and  more  or  less  pronounced  attacks  of 
dyspnoea  at  night.  Children  who  thus  suffer  are  extremely  liable  to  a  re- 
currence whenever  they  take  cold,  and  it  is  not  uncommon  for  mothers  to  say 
that  their  child  is  very  subject  to '  croup.'  Though  these  attacks  are  alarming, . 
they  are  rarely  fatal,  thus  contrasting  with  laryngismus  ;  but  it  must  be  re- 
membered that  the  latter  is  frequently  associated  with  general  convulsions, 
and,  moreover,  occurs  at  an  age  when  spasm  of  the  glottis  is  necessarily 
dangerous  if  severe  on  account  of  the  weakness  of  the  respiratory  muscles 
and  want  of  rigidity  in  the  chest  walls.  Children  who  have  chronically 
enlai'ged  tonsils  or  nasal  adenoids  are  exceedingly  apt  to  suffer  from 
spasmodic  laryngitis. 

These  attacks  of  spasmodic  croup  differ  very  much  in  severity  ;  in  some 
cases  they  are  very  mild,  but  on  account  of  their  occurring  at  night, 
and  the  dread  in  which  all  forms  of  croup  are  held,  they  are  exceedingly 
apt  to  alarm  the  friends.  Several  children  in  the  same  family  may  suffer, 
and  there  is  often  a  history  of  these  attacks  to  be  obtained  in  other  members 
of  the  family. 

Treatment. — Great  care  should  be  exercised  to  protect  children  subject 
to  such  attacks  from  cold.  A  dainp  house  or  a  damp  situation  should  be 
avoided,  and  exposure  to  the  cold  east  winds  of  spring  should  be  carefully 
guarded  against.  Great  benefit  is  usually  derived  from  residence  at  the  sea- 
side. Cold  sponging  with  tepid  salt  and  water  every  morning  on  getting  up 
will  greatly  assist  in  keeping  the  child  free  from  attacks.  Warm  woollen 
clothing  should  be  worn  next  to  the  skin,  and  care  taken  that  the  legs  and 
neck  are  well  protected.  Enlarged  tonsils  or  adenoids  must  be  removed. 
During  the  attack  most  relief  is  given  by  applying  hot  sponges  to  the  throat 
and  by  administering  an  emetic  of  ipecacuanha  powder  (5  to  10  grains)  or  a 
teaspoonful  or  two  of  ipecacuanha  wine.  As  the  child  gets  older  he  becomes 
less  and  less  liable  to  these  attacks,  which  cease  altogether  before  puberty  is 
reached. 

Compression   of  Trachea.     Spasm  of  Glottis 

An  abscess  or  tumour  in  the  posterior  mediastinum  may  compress  the 
trachea  within  the  chest  and  give  rise  to  obstruction  to  the  entrance  of  air 
into  the  lungs  and  also  spasm  of  the  glottis.  The  symptoms  of  such  an  event 
are  a  '  metallic  '  or  '  croupy '  cough,  noisy  stridulous  breathing,  orthopnoea  and 
attacks  of  difficulty  in  breathing,  especially  at  night.  Later,  probably,  there 
will  be  noted  marked  obstruction  to  the  entrance  and  exit  of  air  to  and  from 


Compression  of  Trachea — Catarrhal  Laryngitis  329 

the  chest.  There  may,  in  addition,  be  choking  attacks,  or  difficuUy  of 
swallowing  from  pressure  on  the  oesophagus,  and  dilated  jugular  veins  from 
obstruction  to  the  venous  circulation.  The  compressing  abscess  may  arise 
from  caries  of  the  bodies  of  the  upper  three  or  four  dorsal  vertebrirE,  from  the 
mediastinal  glands  or  thymus.  Lympho-sarcoma  of  the  mediastinal  glands 
may  give  somewhat  similar  symptoms.  The  following  cases  illustrate 
mediastinal  abscesses.     {Sec  also  Spinal  Caries.) 

Tiiboxiilar  Abscess  of  the  Thymus;  Pressure  on  the  Trachea;  Tracheotomy. — 
Margaret  S. ,  aged  20  months  ;  admitted  November  24,  1892.  Mother  states  she  has  been 
weakly  from  birth  and  subject  to  bronchitis.  Five  days  ago  she  began  to  cough  and 
breathe  witli  difficulty.  Sweats  a  good  deal,  and  cannot  lie  down  ;  her  lips  are  blue  at 
times.  On  admission  the  child  was  cyanosed  and  there  was  much  orthopnoea ;  she  was 
given  three  teaspoonfuls  of  vin.  ipecac,  in  divided  doses,  but  she  was  not  sick.  A  few 
liours  after  tracheotomy  was  performed  by  Mr.  Westmacott,  but  it  failed  to  relieve  the 
breathing,  and  she  died  two  hours  after.  Post-7norie?n. — On  removing  the  sternum  an 
enlarged  thymus  was  noted,  extending  from  the  upper  border  of  the  sternum  to  the  bifur- 
cation of  the  trachea,  and  lying  in  contact  with  the  trachea,  and  evidently  compressing  it. 
Some  caseous  lymphatic  glands  were  adherent  to  the  mass.  On  section  it  was  found  to  con- 
tain a  large  abscess  cavity  filled  with  thick  pus.  There  were  some  miliary  tubercles  and 
broncho-pneumonia  in  both  lungs. 

Caries  of  Cervical  Spine  ;  Abscess  compressing  CEsophagus  and  Trachea. — Richard  L., 
aged  3  years  ;  admitted  February  19,  1894.  Mother  states  for  the  last  fortnight  he  has 
had  a  barking  cough  and  wheezing  ;  he  gets  feverish  and  restless  at  night.  On  examination 
it  was  noted  he  had  a  harsh  metallic  cough  and  husky  voice  ;  prolonged  e.xpiration  and 
rhonchus  all  over  the  chest.  March  19. — For  the  last  week  the  breathing  has  been  much 
worse,  noisy,  and  markedly  stridulous  ;  the  cough  metallic,  and  some  recession  of  the 
chest.  April  11. — Breathes  with  a  croupy  sound;  has  attacks  of  difficult  breathing  at 
night ;  gets  blue  and  distressed.  Air  enters  the  chest  with  a  long-drawn  sibilant  sound, 
is  held,  and  then  slowly  goes  out.  Resonance  is  bo.xy  over  the  sternum.  Face  puffy  ; 
no  enlarged  veins.  May  14. — Lips  and  fingers  somewhat  cyanosed.  Sits  up  if  awake, 
but  when  asleep  lies  down,  though  always  raised  more  or  less  on  pillows.  Swallows 
solids  and  liquids  fairly  well.  July  10. — Temperature  been  irregular  since  last  note  ; 
varies  97°  to  100°.  Breathing  has  improved  of  late  ;  there  is  a  tendency  to  choke  when 
he  feeds.  September  11. — All  laryngeal  symptoms  have  disappeared.  Chokes  when  he 
feeds  ;  no  post-pharyngeal  abscess  ;  no  pain  in  the  neck,  but  he  cannot  hold  his  head  up, 
and  the  last  two  cervical  vertebrse  are  very  prominent ;  he  cries  with  pain  if  his  head  is 
rotated.  Temperature  98°  to  101°.  October  13. — Much  worse  ;  for  some  time  past  has 
been  wasting ;  hectic  temperature  ;  had  a  bad  attack  of  dyspncea  early  this  morning  ; 
much  \omitihg,  pus  running  from  nose  and  mouth.  Death  October  23.  Post-martem. — 
Mediastinal  glands  enlarged,  but  not  caseous  ;  a  small  cicatrix  at  the  apex  of  left  lung  ; 
bronchitis,  but  not  tubercle.  In  upper  part  of  the  posterior  mediastinum,  and  behind  the 
oesophagus  is  an  abscess  cavity  holding  .about  Jij  ;  it  has  compressed  the  oesophagus  and 
opened  into  it.  The  trachea  has  been  flattened  for  a  couple  of  inches  opposite  the  abscess. 
Posterior  wall  of  abscess  cavity  formed  by  spinal  meninges  in  position  of  seventh  cervical 
and  upper  three  dorsal,  the  bodies  having  completely  disappeared. 


Catarrbal  Xiaryngitis 

Children  of  all  ages  are  liable  to  suffer  from  a  catarrh  of  the  larynx  and 
trachea,  though  it  is  perhaps  most  conmion  and  is  certainly  most  dangerous 
during  the  first  two  or  three  years  of  life.  These  attacks  differ  somewhat  from 
those  of  spasmodic  croup  just  described,  inasmuch  d.s  there  may  be  no  violent 
exacerbation  at  night,  yet  in  many  cases  all  the  symptoms  are  apt  to  be  worse 
towards  evening.      In  both  cases  there  is  laryngeal  catarrh  and  laryngeal 


330  Diseases  of  the  Respiratory  Apparat7is 

spasm,  and  they  difier  only  in  degree ;  in  the  spasmodic  variety  there  is 
usually  little  catarrh,  but  severe  attacks  of  spasm  of  the  glottis  \  in  the 
catarrhal  variety  the  catarrh  is  much  more  severe,  and  perhaps  the  spasm  is 
not  well  marked,  but  all  these  cases  ai'e  apt  to  become  much  worse  at 
night,  apparently  from  the  presence  of  niore  or  less  spasm.  They  are 
mostly  the  result  of  cold,  exposure  to  cold  winds  or  a  chill,  and  they  may  be 
associated  with  measles,  either  belonging  to  the  premonitory  symptoms  or 
following  the  disappearance  of  the  rash.  The  attacks  are  preceded  for  the 
most  part  by  coryza,  feverishness  and  cough,  the  first  suspicious  symptom 
being'  the  changed  character  of  the  cough,  which  is  at  first  hard  or  hoarse, 
and  then  assumes  the  characteristic  '  croupy '  or  '  brassy '  character,  which 
announces  that  there  is  some  stenosis  of  the  larynx.  An  examination  of  the 
fauces  will  probably  show  enlarged  and  congested  tonsils  with  excessive 
secretion,  and  if  the  epiglottis  can  be  seen,  the  mucous  membrane  will  be 
found  to  be  of  a  pinker  colour  than  usual ;  but  it  is  rarely  possible  to  get  a 
view  of  the  larynx  by  means  of  the  laryngoscope.  As  the  symptoms  become 
more  marked,  the  air  is  heard  to  enter  the  larynx  with  a  hissing  sound,  there 
is  dyspnoea,  the  alte  nasi  work,  the  chest  walls  fall  in  during  inspiration,  and 
there  is  often  much  distress.  In  some  cases  the  child  has  to  be  propped  up 
in  bed,  and  pays  no  heed  to  its  toys,  its  whole  attention  being  taken  up  in  its 
efforts  to  breathe.  The  fever  is  variable,  rarely  high,  usually  ioo°  to  ioi°  ; 
the  pulse  is  quick  and  hard.  In  most  cases  the  symptoms  are  milder  than 
those  just  described,  there  being  only  a  croupy  cough  and  some  acceleration 
of  breathing.  In  the  later  stages  the  secretion  becomes  freer  and  muco- 
purulent. On  the  other  hand,  the  case  may  become  so  urgent  that  intubation 
or  tracheotomy  is  required  to  stave  oft  impending  death,  though  usually  the 
effects  of  treatment  render  this  unnecessary.  Cases  of  simple  catarrhal 
laryngitis  in  children  rarely  present  the  picture  of  stenosis  of  the  larynx 
which  is  seen  in  the  membranous  variety  ;  there  is  probably  the  '  croupy ' 
cough  and  frequent  breathing,  but  between  whiles,  especially  after  a  fit  of 
coughing,  the  child  is  comparatively  comfortable,  and  falls  into  an  easy 
sleep.  The  prognosis  depends  upon  the  diagnosis  ;  if  the  case  is  one  of 
catarrhal  laryngitis  and  the  child  is  over  2  or  3  years  of  age,  there  is  strong 
probability  that  it  will  recover.  The  younger  the  child,  the  greater  is  the 
danger. 

Treatment. — The  first  appearance  of  '  croupy '  symptoms  should  never  be 
neglected  ;  the  hard  metallic  cough,  when  once  heard,  should  be  the  signal 
for  placing  the  child  in  a  warm  room,  where  the  temperature  is  maintained 
at  60°  or  65°  both  day  and  night,  giving  at  the  same  time  fluid  food  or  sops, 
demulcent  drinks,  and  medicines  which  promote  diaphoresis.  If  the  sym- 
ptoms become  more  pronounced,  the  child  must  be  confined  to  its  cot,  and  a 
tent  rigged  over  it  by  means  of  sheets  stretched  over  cords  or  a  clothes- 
horse,  so  as  to  protect  the  patient  from  draughts,  and  a  moist  atmosphere 
must  be  secured  by  the  aid  of  the  steam  kettle.  Some  carbolic  acid  or  tr. 
benzoin  co.  may  be  placed  in  the  kettle.  The  temperature  inside  the  tent 
should  be  maintained  at  about  70°,  and  steam  from  a  kettle  allowed  to  play 
freely  into  it,  so  as  to  render  the  air  thoroughly  warm  and  moist.  The  usual 
tendency  of  the  friends  of  the  patient  is  to  overdo  the  steam  and  maintain 


Catarrhal  Laryngitis  33  I 

toohiyli  a  temperature,  so  tliat  it  is  not  uncommon  tcj  find  the  patient  almost 
parboiled. 

During  the  early  stages  of  lar)'ngitis,  when  there  is  much  swelling  of  the 
mucous  membrane  of  the  larynx,  with  little  secretion,  the  steam  gives  more 
or  less,  at  least  temporarj^,  relief.  This  is  most  marked  in  the  cases  of  hospital 
patients  who  have  been  much  exposed  before  being  admitted  ;  in  these  cases 
the  amount  of  relief  given  by  the  steam  tent  is  often  an  important  element  in 
the  diagnosis  of  catarrhal  versus  membranous  croup.  A  steam  kettle  should 
be  heated  by  means  of  a  spirit  lamp  rather  than  by  gas  or  by  placing  it  on 
the  fire,  as  in  the  latter  case  the  patient's  cot  has  to  be  placed  close  to  the 
fire.  The  products  of  the  combustion  of  gas  are  objectionable,  especially  in 
a  small  room.  Local  applications  applied  over  the  larynx  in  the  form  of 
hot  sponges  or  spongio-piline  wrung  out  of  hot  water  are  often  of  much 
service.  The  sponges  should  be  taken  out  of  the  hot  water  and  squeezed 
by  wringing  in  a  piece  of  flannel  and  used  continuously  ;  but  if  this  exhausts 
the  child  too  much,  a  piece  of  spongio-piline  may  be  secured  in  situ  by  tapes 
and  renewed  every  half-hour.  An  emetic  in  this  stage  is  often  of  much 
value  in  relieving  the  breathing  and  producing  free  expectoration,  ipe- 
cacuanha powder  answering  very  well.  Five  grains  may  be  given  in  syrup  of 
orange  peel  every  ten  minutes  till  vomiting  is  produced.  Sulphate  of  copper 
in  gr.  \  to  gr.  ^  doses,  repeated  in  a  few  minutes,  will  generally  produce 
\omiting.  It  is  useless  to  repeat  emetics  if  they  fail  to  give  relief.  It  need 
hardly  be  said  that  it  is  wrong  to  give  emetics  in  the  later  stages,  when  the 
breathing  has  become  laboured  and  the  lips  blue  or  pallid  ;  to  give  emetics 
under  these  circumstances  is  to  risk  failure  and  to  waste  invaluable  time.  Of 
medicines,  antimony  unquestionably  holds  the  first  place,  and  in  sthenic  cases 
should  be  given  with  a  free  hand,  though  as  an  emetic  it  is  too  slow  and 
nauseating.  Either  the  wine  or  tartar  emetic  may  be  given,  in  combination 
with  citrate  of  potash  or  acetate  of  ammonia.  (F.  46.)  Tartar  emetic  may 
be  given  in  powder  or  in  '  tabloids,'  gr.  ^V  to  gr.  ^V  every  two  or  three  hours, 
according  to  age.  Both  ipecacuanha  and  aconite  in  small  and  repeated 
doses  are  useful. 

The  only  food  admissible  is  milk  diluted  with  barley  water  or  soda  water, 
preferably  given  warm  to  assist  in  producing  perspiration.  In  most  cases  of 
catarrhal  laryngitis  relief  of  the  most  urgent  symptoms  follows  this  line  of 
treatment,  though  probably  for  several  days  many  of  the  symptoms  will 
remain,  with  exacerbations  at  night  ;  in  such  cases  the  antimony  may  be 
pushed,  nauseating  doses  being  given. 

The  question  as  to  whether  intubation  or  tracheotomy  should  be  per- 
formed is  always  a  difficult  one,  inasmuch  as  in  many  cases  the  most  urgent 
symptoms  will  disappear  under  the  influence  of  treatment,  and  the  operation, 
even  in  the  most  skilful  hands,  adds  another  element  of  danger  to  the  case. 
It  is  impossible  to  lay  down  any  rule  for  the  performance  of  the  operation, 
or  to  select  any  one  symptom  which  is  to  be  taken  as  the  signal.  Dyspnoea 
and  recession  of  the  chest  wall  do  not  necessarily  indicate  any  immediate 
danger,  and  most  of  us  will  have  seen  cases  in  which  there  has  been  indrawing 
of  the  epigastrium  andribs  recover  without  operation.  If,  however,  the  case 
passes  into  a  later  stage  in  which  the  voice  almost  disappears,  the  respiration 
becomes  laboured,  all  the  respiratory  muscles  joining  in  the  attempt  to  draw 


332  Diseases  of  the  Respiratory  Apparatus 

in  air  and  expel  it  from  the  chest,  while  the  distress  and  restlessness  are  on  the 
increase,  it  is  then  quite  certain  that  the  time  has  come  for  affording  relief 
If  there  is  marked  pallor  of  the  face,  coma,  delirium,  or  other  symptom  of 
toxaemia,  there  is  not  a  moment  to  lose. 

The  difficulty  is  in  large  measure  due  to  the  uncertainty  of  our  diagnosis. 
If  we  are  sure  that  we  are  dealing  with  a  case  of  catarrh  pure  and  simple, 
even  though  the  symptoms  of  obstruction  are  threatening,  we  can  afford  to 
wait,  and  give  our  treatment  a  fair  trial  before  proceeding  to  operate,  know- 
ing that  much  of  the  obstruction  is  due  to  spasm,  which  may  at  any  time 
suddenly  subside.  Death  from  asphyxia  must  be  very  rare  in  a  case  of 
catarrhal  laryngitis  over  two  or  three  years  of  age.  But  it  is  comparatively 
seldom  that  we  can  make  a  certain  diagnosis — -at  first,  at  any  rate — between 
catarrhal  and  diphtheritic  laryngitis,  as  it  may  be  only  after  tracheotomy 
has  been  performed,  and  sometimes  even  a  day  or  two  later,  that  membrane 
is  coughed  up.  It  is  often  not  easy  to  decide  as  to  the  time  for  operative 
interference,  but  in  a  case  where  there  was  a  history  of  the  child  having 
suffered  before  from  '  croup,'  and  where  the  breathing  tended  to  get  worse 
at  night  ,and  afterwards  improved  for  a  while  at  least,  we  should  delay 
operative  interference  as  long  as  possible,  in  the  hope  that  improvement 
might  take  place.  On  the  other  hand,  in  a  case  that  steadily  got  worse  with- 
out any  intermissions,  we  should  certainly  advise  operative  interference  in 
good  time,  as  there  would  be  little  chance  of  a  successful  issue  to  the  case 
unless  the  obstruction  were  relieved. 


Diphtberia  of  the  AXv  Passag-es 

Is  membranous  laryngitis  always  diphtheritic?  Can  there  be  diphtheria 
of  the  larynx  without  membrane  being  present?  In  the  great  majority  of 
cases  there  can  be  no  doubt  that  if  membrane  be  present  on  the  tonsils,  epi- 
glottis or  larynx,  the  case  is  one  of  diphtheria  ;  but  it  cannot  be  said,  with  cer- 
tainty, if  there  is  no  membrane  there  is  no  diphtheria.  In  the  present  state  of 
our  knowledge  it  is  not  wise  to  take  up  a  dogmatic  position,  except  in  so  far  as 
to  view  every  case  of  laryngitis,  whether  we  find  membrane  or  not,  with  the 
greatest  suspicion,  as  such  cases  may  turn  out  in  the  end  to  be  diphtheria,  and 
we  may  regret  when  too  late  that  we  did  not  at  first  inject  antitoxic  serum. 
Every  case  of  membranous  laryngitis  should  be  treated  as  diphtheria. 

Symptoms. — The  initial  symptoms  of  membranous  croup,  whether  diph- 
theritic or  not,  are  practically  identical,  inasmuch  as  they  are  those  of  stenosis 
of  the  larynx.  When  the  larynx  is  the  primary  seat  of  the  attack  the  symptoms 
are  those  of  catarrh,  with  restlessness,  feverishness,  and  brassy  cough.  In 
the  course  of  a  day  or  two,  sometimes  sooner,  there  is  more  or.  less  loss  of 
voice  and  the  cough  has  a  peculiar  ringing  or  metallic  character,  which  is 
very  characteristic. 

It  now  becomes  evident  that  there  is  some  obstruction  in  the  larynx,  as 
the  air  enters  the  trachea  with  a  hissing  or  stridulous  sound,  and  the  child 
is  constantly  endeavouring  to  cough  something  up  and  clutches  at  its  neck  as 
if  to  remove  some  obstruction.  The  tonsils  are  usually  swollen,  the  fauces 
reddened,  and  perhaps  the  seat  of  false  membrane.  There  is  marked  rest- 
lessness ;    the  child  wants  to  be  nursed,  then  put  back  again  into  its  cot, 


DipJitheria  of  the  Air  Passages  333 

perhaps  get  a  few  minutes'  sleep,  waking  up  with  a  hoarse  cough  and  difificulty 
of  breathing.  The  voice  now  is  nearly  lost,  the  child  speaking  in  a  whisper 
and  making  itself  understood  with  difficulty.  There  is  marked  dyspnoea, 
which  tends  to  increase  as  the  disease  progresses  ;  the  aUe  nasi  dilate,  the 
extra  inspiratory  muscles  are  called  into  action,  and  the  epigastrium  and  in- 
ferior lateral  region  of  the  chest,  the  intercostal  spaces,  and  supra-sternal  fossa 
are  drawn  in  during  inspiration.  The  expiratory  efforts  are  laboured,  so  that 
the  abdominal  muscles  act  with  some  force,  and  the  air  escapes  through  the 
larynx  with  a  noisy  sound.  So  laboured  and  noisy  is  the  breathing  that  it 
can  be  heard  some  distance  off.  While  the  cliild  goes  from  bad  to  worse, 
there  are  usually  more  or  less  marked  exacerbations  ;  the  child  is  easier 
after  a  fit  of  coughing,  during  which  mucus  or  perhaps  some  membrane  is 
actually  dislodged.     All  the  symptoms  are  apt  to  be  worse  at  night. 

If  no  relief  is  obtained  the  symptoms  of  toxaemia  begin  to  present  them- 
sehes.  There  is  a  marked  pallor  or  lividity  about  the  lips  and  face  ;  per- 
spirations break  out  on  the  forehead  ;  the  restlessness  is  often  intense  ;  the 
child  is  perhaps  drowsy  and  delirious,  perhaps  attempting  to  get  out  of  bed  ; 
presently  complete  insensibility  comes  on,  the  pupils  dilate,  the  attempts  at 
respiration  become  more  and  more  feeble,  and  death  quickly  ensues.  The 
temperatui-e  is  usually  raised  a  degree  or  two  in  the  earlier  stages,  but  may 
be  subnormal  as  the  blood  becomes  more  venous.  An  examination  of  the 
chest  does  not  always  yield  positive  results  as  to  the  state  of  the  lungs.  The 
whistling  or  stridulous  sound  produced  in  the  larynx  is  heard  all  over  the 
chest,  masking  the  vesicular  breath  sounds,  and  making  it  difficult  to 
diagnose  the  condition  of  the  lung.  The  supraclavicular  regions  in  front  are 
usually  unduly  resonant  from  the  presence  of  emphysema,  while  at  the  bases 
posteriorly  the  resonance  is  mostly  impaired  on  account  of  the  lung  being 
collapsed,  or  air  entering  it  very  imperfectly.  The  diagnosis  of  pneumonia 
is  difficult  in  the  absence  of  impaired  resonance,  as  the  typical  signs  maybe 
wanting  on  account  of  the  small  supply  of  air  entering  the  chest  :  moreover, 
the  pneumonic  consolidation  may  be  masked  by  emphysema.  It  is  difficult 
to  diagnose  the  presence  of  membrane  in  the  trachea  and  bronchi ;  but  if 
after  tracheotomy  has  been  performed  the  breathing  is  still  laboured  with 
indrawing  of  the  chest  walls,  there  will  be  strong  reason  to  suspect  that  the 
bronchi  are  obstructed  by  membrane. 

When  the  larynx  is  affected  secondarily  the  symptoms  are  frec|uently 
much  less  marked,  more  especially  if  the  membrane  only  spreads  to  the 
larynx  after  it  has  existed  for  some  days  in  the  pharynx  or  nasal  mucous 
membrane.  In  this  case  the  weakness  and  depression  which  exist  before 
the  laryngeal  complication  supervenes  mask  the  symptoms  of  laryngeal 
stenosis.  There  is  usually  much  less  dyspncea  and  distress  than  when  a 
healthy  child  is  suddenly  attacked.  When  the  primary  seat  of  the  membrane 
is  in  the  bronchi  and  it  ascends  to  the  larynx,  the  symptoms  closely 
resemble  purulent  bronchitis,  as  in  the  following  case  : 

Ascending  Diphtheritic  Croup. — Thomas  Mac,  7  years.  Boy  was  quite  well  till 
February  8.  He  complained  of  his  throat,  and  became  hoarse  ;  he  had  also  a  cough. 
On  February  8  he  came  to  the  Manchester  Throat  Hospital,  where  examination  showed 
the  cords  and  larynx  were  healthy.  February  11 — Seen  by  Mr.  Westmacott  at  the 
Children's  Dispensary  ;  hoarseness  and  signs  of  bronchitis  were  noted,  and  he  was  sent  to 


334  Diseases  of  the  Respiratory  Apparatus 

hospital.  On  admission  lie  is  a  well-nourished  boy,  some  dyspnoea,  but  a  good  colour. 
There  is  recession  of  the  lower  part  of  the  chest.  Pulse,  loo ;  respiration,  28  ;  tempera- 
ture, 99"8^  ;  chest  resonant.  Rhonchi  heard  all  over  chest.  No  enlarged  glands  to  be 
felt  ;  some  diffuse  redness  of  fauces  ;  no  membrane.  Steam  tent ;  sick  twice  after  pulv. 
ipecac,  gr.  xv.  February  12. — There  is  more  marked  recession  than  yesterday ;  spits  some 
purulent  sputa  ;  rales  heard  in  chest.  At  noon,  intubation  by  Mr.  Lea,  coughed  up  much 
stringy  mucus.  Temperature  98°-ioi°  ;  no  membrane.  February  13. — Respiration  easy  ; 
tube  remains.  Temperature  101°.  February  15. — Tube  removed ;  breathes  easil}',  but 
coughs  up  a  good  deal  of  greenish  pus.  Urine  contains  a  trace  of  albumen.  Februar)'  16. 
— Respiration  easy  ;  no  recession  ;  urine  a  large  amount  of  albumen.  Intubation  at  10.45  ! 
coughed  tube  up  in  a  few  minutes.  Intubation  again  at  i  P.M.  ;  much  muco-pus  coughed 
up.  February  17. — Child  much  worse;  great  pallor.  Respiration  32.  Urine  scanty; 
large  amount  of  albumen  ;  weak  pulse,  low  tension.  February  18. — Tracheotomy  this 
morning,  dyspnoea  increasing  ;  no  membrane  seen.  Child  died  of  asthenia  early  morning. 
Post-mortem. — Thin  membrane  extending  down  the  trachea  and  bronchi  to  the  smallest 
bronchi  in  the  lungs  ;  much  mucus  present.  Some  membrane  on  the  epiglottis  and  larynx  ; 
none  on  the  fauces  or  nares. 

Albuminuria  exists  in  a  large  number  of  cases  in  the  early  stages,  in 
nearly  all  in  the  latter  stages  ;  the  urine  may  be  highly  albuminous  and 
scanty.  Occasionally  there  may  be  suppression  of  urine  and  ur^emic  sym- 
ptoms. 

Diagnosis. — The  diagnosis  of  stenosis  of  the  lar^mx  is  not  difficult,  nor  is 
it  likely  to  be  confounded  with  bronchitis  or  broncho-pneumonia  where  the 
obstruction  resides  in  the  bronchial  tubes,  or  Avhere  there  is  extensive  con- 
solidation of  the  lung.  In  larj^ngeal  stenosis  the  air  rushes  through  the 
larynx,  giving  rise  to  a  crowing  or  stridulous  sound,  especially  during  inspira- 
tion, but  there  is  obstruction  to  the  expiration  also  ;  the  respiratory  move- 
ments are  laboured,  as  if  to  overcome  the  obstruction,  and  with  this  there  is 
marked  recession  or  sucking  in  of  the  chest  walls  during  inspiration.  There 
is  loss  or  great  impairment  of  voice.  In  pneumonia  or  bronchial  obstruc- 
tion, the  dyspnoea  may  be  great  and  the  respirations  frequent,  with  much 
indrawing  of  the  chest  wall,  but  there  is  no  stridor  or  loss  of  voice.  The 
diagnosis  of  obstruction  of  the  bronchial  tubes,  in  addition  to  stenosis  of  the 
larynx,  as  in  those  cases  where  the  membrane  has  spread  downwards  or 
where  there  is  an  accumulation  of  mucus  below  the  larynx,  is  difficult  and 
uncertain  ;  but  in  all  such  cases  the  dyspnoea  will  be  great,  and  tracheotomy 
urgently  required,  and  the  presence  of  obstructed  bronchi  would  not  contra- 
indicate  operation,  as  an  opening  in  the  trachea  would  favour  the  coughing 
up  of  the  obstructing  material. 

The  diagnosis  between  diphtheria  and  non-diphtheritic  croup  is  often  a 
matter  of  difficulty  by  clinical  observations  alone,  and  until  the  case  has 
remained  under  observation  for  some  hours  or  days  often  impossible.  Even 
after  tracheotomy  has  been  performed,  the  nature  of  the  case  may  still  be 
doubtful,  inasmuch  as  thick  fibrinous  mucus  may  be  coughed  up  with  no 
distinct  membrane,  and  recovery  may  take  place  without  the  diagnosis  having 
been  determined.  The  question  of  diphtheria  or  not  diphtheria  is  one  of  the 
greatest  importance,  but  unfortunately  there  is  not  much  that  can  be  said 
with  certainty.  It  is  easy  to  say  that  in  diphtheritic  croup  there  is  asthenia, 
while  in  catarrhal  laryngitis  the  attack  is  sthenic  in  nature.  But,  as  a 
matter  of  fact,  it  occurs  in  practice  that  if  the  primary  seat  of  the  diphtheria 
is  the  larynx,  the  first  and  only  symptoms  are  those  of  stenosis  of  the  larynx. 


Diphtheria  of  the  Air  Passages  335 

rind  the  pallor  and  depression  and  asthenia  which  result  are  due  to  the 
toxtemia  produced  by  want  of  oxygen,  rather  than  by  the  working  of  the 
diphtheritic  poison.  It  is  for  this  reason  that  the  symptoms  of  membranous 
formations  are  practically  the  same  whether  produced  by  diphtheria  or  not. 
If,  however,  the  larynx  is  affected  after  the  existence  for  some  days  of 
diphtheria  of  the  fauces,  the  symptoms  are  necessarily  modified.  The 
diagnosis  of  diphtheria  when  primarily  situated  in  the  larynx  has  often  to  be 
made  less  from  the  symptoms  of  the  patient  than  from  his  surroundings. 

If  diphtheria  is  epidemic  at  the  time,  or  if  the  fauces  are  covered  with 
membrane,  or  there  is  albumen  present  in  the  urine,  the  case  is  almost  cer- 
tainly diphtheritic.  '  The  discovery  of  Loefifler's  D-bacillus  in  the  secretions 
would  place  the  diagnosis  beyond  doubt,  and  in  every  case  with  suspicious 
laryngeal  symptoms  a  swob  should  be  taken  and  submitted  to  a  competent 
bacteriologist.  This,  however,  in  any  case  takes  time,  and  it  is  not  always 
possible,  especially  in  country  districts,  to  obtain  the  services  of  a  skilled 
bacteriologist. 

Stenosis  of  the  larynx  may  be  caused  in  other  ways  than  by  the  exudation 
of  membrane  ;  the  larynx  may  be  compressed  by  an  abscess  situated  pos- 
teriorly between  the  larynx  and  oesophagus,  or  even  laterally  ;  in  this  case 
there  will  be  difficulty  of  swallowing  as  well  as  dyspnoea.  The  trachea  may 
be  compressed  below  the  larynx  by  an  enlarged  thyroid  or  new  growth,  but 
the  history  of  the  case  as  well  as  the  local  enlargement  would  distinguish 
between  the  two.  In  infants  and  young  children  spasm  of  the  glottis  will  in 
rare  cases  simulate  membranous  laryngitis,  as  in  the  case  given  (p.  326). 

PatJiological  Anatomy. — The  post-iijoi'tem  appearances  found  in  those 
who  have  died  of  membranous  or  diphtheritic  croup  differ  according  to  the 
immediate  cause  of  death.  In  the  majority  of  cases  this  is  due  to  the  forma- 
tion of  membrane  below  the  tracheotomy  wound  and  to  the  lungs  becoming 
choked  or  collapsed.  In  such  cases  membrane  may  be  found  beginning 
at  the  epiglottis  and  extending  downwards  to  the  smallest  bronchi.  As  a 
rule  the  membrane  is  tough  and  firmly  adherent  to  the  epiglottis  and  larynx, 
being  separated  with  difficulty,  while  lower  down  the  membrane  is  far  less 
tough,  and  is  much  more  easjly  detached  ;  the  bronchi  usually  contain  semi- 
purulent  fluid,  and  the  bases  of  the  lungs  are  usually  pneumonic  or  collapsed 
while  the  .apices  are  emphysematous.  In  some  cases  death  results  from 
asthenia  or  from  septic  poisonings,  the  result  of  the  diphtheritic  infection  ;  in 
such  cases  the  trachea  and  bronchi  may  be  free  from  secretion.  It*  is  ex- 
ceedingly rare  to  find  at  the  post-mortem  that  the  membrane  is  confined  to 
the  larynx  in  those  cases  where  tracheotomy  has  been  performed.  Broncho- 
pneumonia is  frequently  present. 

Treatment. — Every  case  of  laryngitis  occurring  in  a  child  should  be  at 
once  isolated,  as  what  may  appear  in  the  early  stages  to  be  a  mild  case  of 
catarrhal  laryngitis  may  in  the  end  prove  to  be  diphtheritic.  There  are  mild 
attacks  of  diphtheria  of  the  larynx,  just  as  there  are  mild  cases  of  diphtheria 
of  the  tonsils  and  fauces.  In  the  early  stages  the  secretion  coughed  up  may 
be  muco-purulent  only,  and  later,  either  before  or  after  tracheotomy  or  in- 
tubation has  been  performed,  the  secretion  may  be  membranous. 

In  every  case  of  laryngitis  where  there  is  even  a  suspicion  of  diphtheria 
1,000  to  1,500  units  of  antitoxic  serum  should  be  injected  without  delay.      It 


>iT,6  D/snrs^s  of  tJie  Respii-atory  Apparatus 

may  be  impossible  to  make  a  diagnosis  of  diphtheria  in  those  cases  in  which 
the  laiynx  is  first  attacked,  but  inasmuch  as  diphtheria  of  the  larynx  is  an 
exceedingly  fatal  disease,  and  as  the  success  of  the  serum  treatment  depends 
upon  it  being  begun  within  24  or  48  hours  of  the  commencement  of  the 
illness,  it  is  better  to  err  on  the  safe  side  and  treat  a  suspicious  case  as 
diphtheria  from  the  very  first.  If  in  a  case,  seen  for  the  first  time,  there  is  a 
whitish  or  yellowish  exudation  either  in  points  orpatcheson  the  tonsils  or  fauces, 
we  should  not  hesitate  to  use  antitoxin.  Our  experience  agrees  with  that  of 
others,  that  in  some  cases,  at  least,  improvement  in  the  symptoms  takes  place 
within  12  or  24  hours,  and  in  cases  in  which  tracheotomy  is  necessary,  the 
mortality  is  less  now  than  formerly  it  was  without  antitoxin.  The  antitoxin 
apparently  has  the  effect  of  loosening  the  membrane  and  preventing  extension. 
Goodall  comes  to  the  conclusion,  from  the  consideration  of  the  statistics  of 
various  institutions,  that  out  of  every  100  cases  of  tracheotomy  for  diphtheria 
in  the  preantitoxin  days  not  more  than  29  were  saved,  now  at  least  53  recover  ; 
and  in  those  cases  not  operated  on  in  the  old  days  not  more  than  48  recovered, 
now  at  least  75  cases  end  in  recovery. 

Much  that  has  been  said  under  the  head  of  treatment  in  catarrhal  laryn- 
gitis will  apply  to  the  treatment  of  diphtheritic  laryngitis.  A  steam  tent 
should  be  provided,  and  warmth  and  heat  should  be  applied  externally  to 
the  larynx,  though  any  blistering  or  abrasion  of  the  skin  must  be  carefully 
avoided.  If  the  case  is  certainly  one  of  diphtheria,  we  doubt  the  value  of 
either  emetics  or  expectorants.  If  there  is  membrane  in  the  larynx  there  is 
small  chance  of  its  being  loosened  or  detached  by  these  means.  We  must 
chiefly  rely  on  the  application  of  steam  from  a  steam-spray  apparatus 
charged  with  some  antiseptic,  and,  above  all,  on  antitoxin  in  relieving  the 
stenosis  of  the  larynx  by  intubation  or  tracheotomy.  Calomel  fumigation 
has  been  used  with  some  success  in  America,  and  is  certainly  worth  a  trial. 
Dr.  Northrup  recommends  that  a  tent  be  rigged  up  over  the  cot  by  means 
of  sheets,  made  fairly  air-tight,  and  of  about  50  cubic  feet  capacity.  1 5  grains 
of  calomel  are  volatilised  every  two  hours  for  two  days  and  two  nights,  and 
then  at  intervals  of  three  hours  for  the  next  twenty-four  hours.  The  calomel 
is  volatilised  by  means  of  a  tin  plate  heated  by  a  spirit  lamp,  and  placed  over 
a  bowl  of  water  so  as  to  prevent  fire  in  case  of  an  upset.  This  treatment  does 
not  produce  ptyalism  ;  if  carried  on  too  long  stomatitis,  diarrhoea,  and  anaemia 
may  supervene.  The  mouth  should  be  kept  swabbed  out,  and  any  seci-etion 
coughed  up  must  at  once  be  removed  and  disinfected.  The  medicinal  treat- 
ment appropriate  for  diphtheria  should  be  given  (see  infj-a).  The  only  food 
should  consist  of  fluids. 

Tracheotomy. — The  operation  of  opening  the  trachea  in  cases  of  mem- 
branous laryngitis  must  be  looked  upon  as  a  means  of  relieving  the  mecha- 
nical obstruction  to  respiration  ;  it  can  in  no  way  influence  the  constitutional 
effects  of  the  disease,  though  it  may  prevent  the  addition  of  gradual  asphyxia 
to  the  other  depressing  influences  of  the  poison.  Further,  we  may,  by  the 
operation,  prevent  the  spread  of  the  membrane  down  the  trachea,  and  thus, 
perhaps,  lessen  the  risk  of  absorption  of  the  virus  as  well  as  get  rid  of  the 
obstruction.^     What  certainly  may  be  looked  for  from  the  operation  is  that 

1    ]'idc  R.  \\'.  Parker. 


Diphtheria  of  the  Air  Passages  337 

death  from  mechanical  obstruction  to  the  upper  segment  of  the  windpipe  may 
be  averted,  and  that  the  distress  caused  by  dyspnoea  may  to  a  great  degree 
be  relieved.  It  must  not  be  forgotten  that  tracheotomy  has  its  own  dangers : 
first  come  the  risks  of  the  operation  itself — haemorrhage,  injury  to  important 
neighbouring  structures,  and  entrance  of  blood  into  the  trachea  ;  later,  there 
are  the  clangers  of  septic  absorption,  the  exposure  of  a  raw  surface  to  the 
diphtheritic  poison,  tracheitis,  pneumonia,  and  so  on,  from  exposure  of  the 
tracheal  mucous  membrane  to  cold  ;  that  this  is  a  real  danger  a  paper  of 
Sir  S.  Wilks  shows. ' 

While  we  have  thus  indicated  the  objections  to  and  the  limited  uses  of 
the  operation,  we  would  yet  urge  its  performance  in  all  cases  where  there  is 
severe  dyspnoea  ;  we  have  no  means  of  knowing  that  the  child  will  die  of 
asthenia,  we  do  know  that  he  \vill  die  of  suffocation  if  unrelieved,  and  the 
other  dangers  mentioned  are  all  usually  avoidable  by  careful  operating  and 
after-management. 

Extreme  prostration  without  distinct  evidence  of  asphyxia,  and  the  pre- 
sence of  pneumonia  or  capillary  bronchitis,  may  be  looked  upon  as  indica- 
tions that  tracheotomy  will  be  of  no  avail.  If  tracheotomy  is  otherwise  in- 
dicated, the  presence  of  bronchitis  may  not  in  all  cases  prevent  the  operation 
being  successful.  We  have  seen  a  case  in  which  it  succeeded  perfectly  under 
these  circumstances  as  far  as  relieving  the  dyspnoea  went,  though  the  child 
died,  when  apparently  convalescent,  from  ulceration  into  the  innominate 
artery. 

The  younger  the  child  the  earlier  should  tracheotomy  be  done  ;  indeed, 
in  children  under  three  years  once  there  is  membrane  in  the  lar^-nx  there 
is  little  hope  but  in  tracheotomy  ;  but  see  p.  336.  Inasmuch  as  the  operation  is 
nearly  always  one  of  urgency,  we  must  be  prepared  to  do  it  under  unfavour- 
able circumstances  as  regards  nursing,  light,  help,  and  appliances.  It  is, 
howe\-er,  usually  possible  to  improvise  fairly  serviceable  arrangements  for 
the  operation  itself.  A  dressing  table  or  the  top  of  a  chest  of  drawers 
in  private  houses  is  the  usual  operating  table.  Candles  give  generally 
the  best  obtainable  light  when,  as  is  so  often  the  case,  the  operation  has  to 
be  done  at  night,  and  care  must  be  taken  that  the  lights  are  entrusted  only 
to  those  members  of  the  household  who  can  be  depended  upon  to  bear  seeing 
the  operation.  These  makeshift  arrangements,  together  with  the  small  size 
and  anatomical  relations  of  the  parts,  the  urgency  of  the  case,  and  the 
movements  of  the  trachea  in  difficult  respiration,  make  this  operation, 
though  often  lightly  spoken  of,  one  of  the  most  anxious  in  surger}'. 

If  possible,  at  least  one  skilled  assistant  should  be  obtained  besides  the 
anaesthetist.  As  regards  anaesthetics,  it  is  in  our  opinion  a  question  to  be 
settled  for  each  case  ;  if  the  child  is  so  asphyxiated  as  to  be  unconscious  of 
pain,  and  not  likely  to  struggle,  it  is  far  better  to  do  without  an  ancesthetic. 
We  have  seen  chloroform  prove  fatal  before  the  operation  was  begun  :  on 
the  other  hand,  if  the  case  is  operated  upon  earlier,  and  the  child  is  conscious 
and  restless,  it  is  on  all  grounds  better  to  give  chloroform. 

The  child  then  should  be  placed  upon   a  table  of  convenient  height,  and 
the  lights,  if  necessary,  arranged    carefully.     Everything   required  in    the 
operation  should  be  laid  out  upon  a  table  or  chair  ready  to  hand  before  the 
1  Guy's  Reports,  ser.  iii.  \"ol.  vi. 


338 


Diseases  of  the  Respiratory  Apparatus 


child  is  taken  out  of  bed,  since  at  any  moment  the  moving  or  the  giving  of 
the  anaesthetic  may  increase  asphyxia  and  demand  instant  action. 

As  soon  as  the  child  is  unconscious,  and  not  before,  since  it  increases  the 
dyspnoea,  one  pillow  should  be  taken  from  beneath  the  head  and  placed 
under  the  shoulders,  so  that  the  head  falls  back  and  fully  exposes  the  front 
of  the  neck.  Parker  recommends  a  wine  bottle  wrapped  in  a  towel  as  a 
neck  support.  The  head  must  be  held  by  an  assistant  exactly  straight,  so 
as  to  avoid  any  chance  of  the  operator  missing  the  mid  line  of  the  neck. 
The  thyroid  cartilage  is  then  to  be  felt  for,  and  an  incision,  one  and  a  half 
or  two  inches  in  length,  according  to  the  size  of  the  child,  made  in  the  middle 
line  from  the  lower  border  of  the  thyroid  cartilage  downwards  nearly  to  the 


Sc  Artery 
ISajptTior  lyiyroid  vein 


Fig.  62. — Anatomy  of  Child's  Trachea.     (From  '  Gray's  Anatomy.') 


top  of  the  sternum.  The  first  incision  should  be  carried  through  the  skin 
and  subcutaneous  fat  ;  the  second  assistant  should  then  draw  the  edges  of 
the  wound  apart  with  retractors,  and  the  operator  should  by  successive  cuts 
divide  the  tissues  until  he  reaches  the  intermuscular  septum  between  the 
sterno-hyoids  or  lower  down  between  the  sterno-thyroids  :  on  reaching  this 
he  should  with  a  director  tear  through  the  line  of  junction,  and  the  assistant 
should  take  them  up  with  the  retractors.  The  tracheal  fascia  will  now  be  ex- 
posed, and  should  be  torn  through  in  like  manner,  and  the  trachea  bared. 
The  tracheal  hook  is  next  fixed  in  the  trachea,  and  drawn  slightly  forwards 
so  as  to  steady  the  windpipe  and  make  it  prominent  ;  a  short,  somewhat 
round-shouldered  knife — i.e.  one  rounded  at  the  back  and  nearly  straight  in 
front — is  then  made  to  pierce  the  trachea,  and  as  soon  as  it  has    entered 


DipJiiJieria  of  the  Air  Passages  339 

the  handle  is  shyhtly  depressed,  and  the  windpipe  is  divided  from  below 
upwards  for  at  least  three-quarters  of  an  inch.  The  knife  is  now  laid 
aside,  the  dilator  passed  mto  the  trachea  and  opened,  and  the  hook  re- 
moved ;  a  free  blast  of  air  and  the  driving  out  often  of  mucus  or  of  niem- 
Ijrane  follows.  If  the  trachea  is  free  from  membrane,  the  tracheotomy  tube 
fitted  with  tapes  is  then  passed  in  between  or  above  the  dilator  blades,  and 
the  dilator  is  removed  ;  as  soon  as  a  blast  of  air  through  the  tube  shows  that 
it  is  in  place,  the  tapes  should  be  tied  round  the  neck,  and  the  operation  is 
over.  The  child  should  be  kept  upon  the  table  well  wrapped  up,  with  a 
warm  sponge  over  the  tube,  for  a  short  time  to  recover  itself,  and  that  it  may 
be  seen  that  there  is  no  bleeding  or  other  complication  ;  after  a  quarter  of 
an  hour  the  inner  tube  may  be  put  in  after  clearing  away  all  coughed-up 
matter,  and  the  child  should  be  put  into  its  cot  and  the  steam  kettle 
arranged. 

Such  are  the  general  outlines  of  the  course  of  an  operation  in  which  there 
have  been  no  complications  and  no  hurry  ;  it  is,  however,  seldom  that  such  a 
favourable  state  of  things  occurs,  and  it  will  be  convenient  to  consider  more 
in  detail  the  various  difficulties  that  may  arise.  First,  then,  one  or  more  large 
\eins,  inferior  thyroid  or  branches  of  the  anterior  jugular,  may  be  met  with  ; 
if  there  is  no  urgency  these  may  be  ligatured,  either  before  or  immediately 
after  division,  or  forcipressure  forceps  applied.  Should,  by  any  rare  chance, 
an  artery  of  any  size  be  wounded,  it  must  of  course  be  treated  in  the  same 
way.  In  all  cases  the  veins  are  necessarily  intensely  congested  when  dyspnoea 
is  marked.  In  order  to  avoid  danger  of  wounding  veins,  some  surgeons 
lay  aside  the  knife  after  the  first  incision  and  tear  through  the  tissues  down 
to  the  trachea  with  dissecting  forceps  or  director. 

Next,  the  most  rigid  care  must  be  taken  to  keep  in  the  middle  line  ;  in 
young  fat  children  it  is  not  difficult  to  miss  the  trachea,  which  in  them  is  not 
only  small,  but  so  soft  as  to  be  readily  compressed  or  pushed  aside  and  so 
missed.  Everyone  has  heard  of,  if  not  seen,  cases  in  which  the  dissection 
has  been  carried  to  one  side  of  the  trachea,  and  thus  the  great  vessels  &c. 
endangered.  In  tracheotomy  low  down,  the  anterior  jugular  vein  is  the  vessel 
most  likely  to  be  injured.     This  is,  of  coui'se,  of  minor  impoi'tance. 

The  depth  of  the  trachea  must  also  be  remembered,  and  the  fact  that  it 
recedes  from  the  surface  towards  the  lower  part  of  the  neck.  The  deep  in- 
cisions must  not  be  carried  too  close  to  the  sternum,  or  the  innominate  vessels 
will  be  endangered,  nor  must  the  trachea  be  opened  so  high  up  as  to  divide 
the  thyroid  cartilage  and  probably  injure  the  vocal  cords  ;  it  is  well,  however, 
to  get  as  low  an  opening  as  practicable,  in  order,  if  possible,  to  be  clear  of 
the  obstruction. 

No  regard  need  be  paid  to  the  thyroid  gland,  nor  should  any  attempt  be 
made  in  children  to  make  a  '  superior '  or  '  inferior  '  tracheotomy.  In  almost 
every  case  in  which  the  operation  has  been  done  examination  will  show  that 
two  or  three  rings  of  the  trachea  and  the  cricoid  cartilage,  together  with,  of 
course,  the  isthmus  of  the  thyroid  gland,  have  been  divided — that,  in  fact, 
a  laryngo-tracheotomy  has  been  done,  and  this  is  as  good  as  any  other 
operation. 

It  is  not  by  any  means  necessary  to  use  a  tracheal  hook  ;  if  it  is  not  em- 
ployed, the  left  forefinger  should  be  used  as  a  guide  and  the  trachea  steadied 

z  2 


340  Diseases  of  the  Respiratory  Apparatus 

by  it  or  between  it  and  the  left  thumb  while  the  knife  is  carried  upwards  by 
the  side  of  the  finger  or  between  it  and  the  thumb;  in  many  cases,  however, 
the  hook  does  undoubtedly  simplify  the  operation. 

It  is  of  great  importance  to  have  the  skin  wound  very  free,  both  to  give 
room  for  the  deeper  steps  of  the  operation  and  to  prevent  the  possibility 
of  discharge  or  air  being  pent  up  in  the  cellular  tissue  of  the  wound  ;  no 
stitches  should  ever  be  put  in.  The  tracheal  opening  should  be  large, 
median,  and  vertical  ;  nothing  is  gained  by  a  small  opening,  and  much  trouble 
may  arise  in  inserting  the  tube.  The  knife  should  enter  the  trachea  some- 
what sharph',  but  not  with  a  stab  or  plunge  which  would  endanger  the 
posterior  wall  ;  cases  have  been  recorded  where  the  knife  failed  to  pierce 
the  mucous  membrane,  and  hence  the  tube  was  passed  into  the  submucous 
tissue ;  in  other  instances  a  tough  diphtheritic  membrane  has  been  pushed 
before  the  knife  and  tube — under  either  condition,  of  course,  no  relief  was 
obtained  hy  the  operation. 

If  there  is  any  large  collection  of  membrane  or  of  thick  mucus  in  the 
trachea,  the  tube  should  not  be  inserted  at  once,  but  the  edges  of  the  tracheal 
wound  should  be  held  apart  for  the  child  to  freely  cough  out  the  contents  of 
the  air  passages,  and  for  the  surgeon  to  clear  them  away  and  examine  the 
surface  of  the  trachea  so  as  to  pick  off  any  visible  membrane  above  or  below 
the  opening.  Parker  advises  the  systematic  use  of  the  dilator  and  swabbing 
out  the  trachea  and  larynx  with  a  feather  dipped  in  solution  of  carbonate  of 
soda  before  putting  in  the  tube.  Systematic  curetting  of  the  trachea  has  been 
done  by  some  operators. 

The  tracheal  aperture  may  be  held  open  either  with  the  dilator  or  with 
artery  forceps,  or  Golding-Bird's  dilator  may  be  worn  for  a  time. 

In  inserting  the  tube  it  is  sometimes  difficult  to  get  it  into  the  slitlike 
orifice  in  the  trachea  ;  under  these  circumstances  the  dilator  is  useful,  or  if 
one  is  not  at  hand,  one  end  of  the  opening  may  be  depressed  by  the  finger 
so  as  to  make  the  aperture  gape.  A  bivalve  tube  is  of  course  the  easiest  to 
insert  for  this  reason,  though  it  is  not  by  any  means  the  best  variety.  The 
surgeon  should  never  be  satisfied  that  the  trachea  is  properly  opened  unless 
free  blasts  of  air  are  driven  out  on  coughing,  nor  that  the  tube  is  in  the  wind- 
pipe unless  air  and  mucus  are  blown  out  through  the  tube  freely. 

The  instrument  most  commonly  used  to  clear  the  trachea  of  membrane 
is  a  feather  ;  some  of  the  shorter  tail  feathers  of  a  pheasant  will  be  found  the 
best — if  the  longer  ones  are  used,  the  end  which  is  too  flexible  should  be  cut 
off.  We  have  had  some  common  brush  pipe-cleaners  tipped  with  coralline 
for  this  purpose,  and  also  a  miniature  bristle  probang  made  to  sweep  out  the 
trachea..  Mem^brane  can  often  be  picked  out  with  forceps.  Aspirators  of  all 
kinds  are  of  use  chiefly  if  not  solely  for  blood  and  the  thinner  form  of  mucus  ; 
adherent  membrane  and  thick  mucus  cannot  be  drawn  out  by  them  ;  neither 
is  sucking  by  the  mouth  any  better,  hence  it  is  not  worth  the  risk  to  the 
operator.  Anyone  who  has  tried  it  will  know  how  impossible  it  is  to  suck 
out  anything  except  the  fluid  material,  and  even  for  this  suction  is  often  un- 
successful. Parker,  however,  strongly  advocates  the  use  of  aspirators  after 
loosening  and  softening  the  membrane  by  instillation  of  carbonate  of  soda.' 
Where  breathing  has  ceased  or  is  becoming  very  feeble,  artificial  respiration 
'  Sodee  carbonat.  3ij.  glycerine  §ij,  water  to  .^viij  (Parker). 


Diphtheria  of  the  Air  Passages  341 

should  be  performed,  and  if  necessary  a  catheter  may  Ije  passed  down  the 
trachea  and  the  lungs  inflated.' 

Such  are  the  more  important  points  about  the  operation  itself  in  cases 
where  everything  can  be  done  deliberately  and  Trousseau's  classical  advice, 
'  Operez  lentement,  tres  lentemcnt,'  followed.  In  many  cases,  however,  if 
the  operator  is  slow  the  child  will  be  dead  before  the  trachea  is  opened,  and 
if  not  actually  dead  the  almost  complete  asphyxia  will  seriously  add  to  the 
dangers  of  the  case.  Under  such  circumstances  it  is  necessary  to  cut  the 
steps  of  the  operation  short  ;  a  free  incision  through  the  skin,  another  down 
to  the  trachea,  and  the  third  upwards  in  the  trachea  itself.  We  ha\'e  often 
had  to  operate  in  this  way  with  three  cuts,  using  no  instrument  except  the 
knife  and  the  tracheotomy  tube  ;  after  the  first  two  incisions  the  left  fore- 
finger is  passed  down  to  the  trachea,  which  is  steadied  by  it  ;  the  opening 
is  made  and  the  finger  kept  as  a  guide  for  the  tube,  which  is  at  once  m- 
serted.  The  finger  and  thumb  may  be  usefully  employed  to  push  back  the 
tissues  on  each  side,  and,  as  it  were,  press  forward  the  trachea.  In  some 
cases  there  is  free  bleeding  for  a  moment  or  two  from  the  engorged  veins  ; 
this  must  be  neglected,  the  tube  put  in  at  once,  and  the  child  instantly 
turned  over  on  its  face  to  prevent  any  blood  from  running  into  the  trachea  ; 
as  soon  as  air  enters  the  lungs  freely  the  circulation  is  re-6stablished  and 
the  venous  bleeding  ceases  without  any  treatment.  The  objection  to  this 
mode  of  operating  is  that  it  is  of  course  more  difficult,  and  there  is  some 
risk  of  blood  getting  into  the  air  passages  ;  it  is,  however,  necessary  in  some 
cases.  In  very  urgent  suffocation  the  operation  may  even  be  done  in  one 
incision  through  skin  and  trachea  upwards,  but  this  can  hardly  ever  be 
necessary,  and  has  several  objections,  the  chief  being  that  in  children  the 
trachea  can  by  no  means  always  be  felt  through  the  skin,  and  there  is 
great  likelihood  of  emphysema  from  insufficiency  of  the  superficial  wound.' 
Even  if  the  child  is  apparently  dead  before  the  trachea  is  opened,  the 
operation  should  be  rapidly  completed,  a  long  feather  passed  down  the 
trachea  and  withdrawn,  and  the  artificial  respiration  performed.  Recovery 
will  often  follow  even  if  respiration  has  ceased  for  what  appears  a  very  long 
time. 

It  is  well  to  remember  that  venous  bleeding  in  tracheotomy  is  always 
more  formidable  in  appearance  than  in  reality,  and  always  ceases  at  once 
after  the  trachea  is  freely  opened. 

Emphysema  occurring  at  the  time  of  the  operation  is  due  to  too  small  a 
skin  wound  or  to  opening  up  the  cellular  tissue  in  attempts  to  pass  the  tube  ; 
it  may  be  very  extensive  and  spread  down  into  the  thorax  ;  in  such  cases  it 
is  sometimes  fatal  from  pressure  upon  the  lungs.  Champneys  has  shown 
experimentally  that  there  is  serious  danger  of  mediastinal  emphysema  and 
pneumo-thorax  when  artificial  respiration  or  sudden  violent  inspiratory  effort 
is  made  after  division  of  the  deep  cervical  fascia  ;  hence  the  tube  or  dilator 
should  be  put  in  quickly  and  the  fascia  disturbed  as  little  as  possible.^ 

1    Fziff  Jennings,  Arch.  Pcediatr.  September  1884. 

-  St. -Germain  operates  by  one  incision  downwards,  beginning  by  perforating  the  crico- 
thyroid membrane.  Neither  this  plan  nor  operation  with  the  thermo-cautery  has  anything 
to  recommend  it. 

^  Mcd.-Chir.  Trans.  1882. 


342  Diseases  of  the  Respiratory  Apparatus 

A  possible  danger  from  entry  of  air  into  a  wounded  vein  need  only  be 
mentioned  ;  instant  pressure  on  the  vein  and  rapid  opening  of  the  trachea 
are  the  remedies. 

Opinions  differ  greatly  as  to  the  best  form  of  tracheotomy  tube  for 
immediate  use.  The  bivalve  is  the  easiest  to  insert  ;  the  lobster-tailed  tube 
of  Durham  is  open  to  the  objection  that  it  is  very  difficult  to  clean  ;  probably 
Parker's  so-called  angular  tube  is  the  best,  and  is  certainly  anatomically  the 
most  correct  ;  it  has  also  the  advantage  of  being  polished  inside.  It  is, 
however,  a  matter  of  little  importance  what  shape  of  tube  is  put  in  for  the 
first  few  hours,  provided  it  is  of  sufficient  size  and  has  a  movable  shield  to 
allow  it  to  lie  evenly.  The  largest  size  that  the  trachea  will  admit  should 
always  be  u.sed  to  give  as  much  breathing  space  as  possible  and  to  prevent 
play  of  the  tube  in  the  trachea.  Parker  has  shown  that  the  diameter  of  the 
windpipe  is  exceedingly  variable,  and  no  rules  for  size  in  correspondence 
with  age  can  be  given.  In  any  case  it  is  advisable  to  change  the  tube  after 
twenty-four  or  forty-eight  hours,  and  this  gives  time  for  the  substitution  of  a 
Parker's  tube  for  any  other  that  may  have  been  used  at  the  moment.  After 
ninety-six  hours  the  metal  tube  can  often  be  replaced  by  a  Morrant  Baker's 

rubber  one,  or  at  least  a  metal  tube  of  differ- 
ent length  from  that  first  employed,  or,  better 
still,  the  tube  may  be  in  favourable  cases  left 
out  altogether. 

As  soon  as  the  trachea  has  been  cleaned 
and  the  child  has  become  quiet  after  the 
operation,  i.e.  usually  in  about  half  an  hour 
or  less,  the  child  should  be  removed  to  the 
tent,  the-  arrangement  of  which  has  been 
already  described. 
Fig.  63.— Parker's  Tube.  The  lower  part  of  the  wound  should  be 

dusted  over  with  iodoform,  and  a  piece  of 
gauze  slipped  beneath  the  shield  of  the  tube  to  protect  the  skin  and 
wound  from  it.  If  the  edge  of  the  shield  cuts  into  the  wound,  the  tube 
does  not  fit  well  and  probably  the  inner  end  is  pressing  upon  the  tracheal 
wall ;  it  is  either  too  long  in  the  straight  part  or  the  curve  is  wrong.  A 
single  layer  of  gauze  wet  with  1-40  carbolic  or  some  other  antiseptic  solution 
should  be  laid  over  the  mouth  of  the  tube  and  removed  when  there  is  any 
coughing. 

The  child  must  be  constantly  watched,  and  at  the  least  sign  of  dyspnoea 
or  any  cough  the  tube  should  be  cleaned  with  a  feather,  and  coughing 
excited,  watching  for  the  moment  when  mucus  appears  at  the  mouth  of  the 
tube  to  wipe  it  away  before  it  is  drawn  in  again.  The  inner  tube  should  be 
put  in  as  soon  as  the  child  has  settled  down,  and  taken  out  every  half-hour 
oroftener  at  first  to  be  cleaned.  Special  watch  must  be  kept  for  any  sudden 
plugging  of  the  tube  by  pieces  of  detached  membrane  or  thick  mucus — a 
frequent  cause  of  sudden  death  after  tracheotomy — immediate  removal  of  the 
tube  and  membrane  is  required  in  such  circumstances.  Abundant  discharge 
of  thin  mucus  is  a  good  sign,  in  so  far  as  there  is  less  likelihood  of  there 
being  any  membrane  in  the  trachea  if  free  secretion  occurs. 

Af/er-ina/iagcment. — Success  in  the  results  of  tracheotomy  cases  depends 


Diphtheria  of  the  Air  Passages  343 

more  upon  after-management  tlian  upon  anything  else,  and  if  surj^eons 
could  nurse  their  own  cases  the  mortality  after  the  operation  would  be  much 
less.  Constant  watchfulness,  readiness  to  remove  the  tube  altogether  and 
clean  out  the  trachea — if  membrane  continues  to  form,  this  should  be  done 
at  least  once  daily  ;  the  timely  administration  of  stimulants,  regulation  of 
temperature  and  moisture  are  essentials,  and  can  only  be  satisfactorily  seen 
to  by  the  surgeon  himself  Cocks  '  well  insists  upon  this,  and  points  out 
that  sudden  obstruction  is  most  often  due  to  inspissated  mucus,  not  to  mem- 
brane ;  this  thick  mucus  is  secreted  generally  about  twenty-four  hours  after 
the  operation,  and  at  the  end  of  three  or  four  days  the  discharge  becomes 
thinner  and  more  puriform  (Jennings). 

It  is  well  to  feed  the  child  by  nutrient  enemata  for  the  first  few  hours,  but 
if  he  is  thirsty  a  few  teaspoonfuls  of  iced  milk  may  be  given.  During  the 
first  few  days  the  milk  not  infrequently  comes  out  in  part  through  the 
tracheotomy  tube  from  imperfect  closure  of  the  glottis  during  deglutition,  and 
not,  as  might  be  supposed,  from  any  accident  to  the  oesophagus  ;  on  account 
of  this  occurrence  it  has  been  advised  to  give  more  solid  food  by  the  mouth. 
A  certain  amount  of  risk  is  incurred  from  this  imperfect  power  of  swallowing, 
in  that  food  may  pass  into  the  lungs  and  set  up  the  so-called  '  deglutition 
pneumonia;'  any  such  danger  may  be  avoided,  as  pointed  out  by  Dr. 
Habershon,  by  feeding  the  child  through  a  soft  catheter  ;  from  2  to  6  oz.  of 
milk  may  be  given  in  this  way  every  four  hours,-  but  the  plan  is  rarely 
required. 

If  possible  the  tracheotomy  tube  should  be  removed  altogether  on  the 
fourth  or  fifth  day,  but  this  must  depend  upon  how  far  the  disease  has  sub- 
sided ;  if  membrane  is  still  coming  away,  the  tube  must  remain,  and  it  may 
be  the  eighth  or  tenth  day  before  it  is  got  rid  of.  If,  as  not  infrequently 
happens,  the  dyspnoea  returns  on  closure  of  the  orifice  of  the  tube  with  the 
finger  (always  supposing  that  the  tube  has  a  perforation  at  the  bend)  or  on 
its  removal,  the  difficulty  is  due  to  the  presence  either  of  membrane  or  of 
granulation  tissue,  which  may  form  a  polypoid  mass  springing  from  the  site 
of  some  patch  of  membrane,  from  the  edge  of  the  wound,  or  from  an  ulcer 
due  to  the  pressure  of  the  tube.  Granulation  masses,  according  to  Parker, 
are  most  common  about  the  fourth  to  the  eighth  day,  and  may  be  expected 
if  there  are  exuberant  masses  on  the  margin  of  the  tracheal  wound.  Morell 
Mackenzie  says  they  occur  from  the  fifteenth  to  the  thirtieth  day,  never  after 
two  months.  Parker  treats  them  by  the  application  of  nitrate  of  silver. 
Black  patches  seen  on  the  outer  tube  when  it  is  removed  are  said  to  indicate 
ulceration  at  the  corresponding  spot  of  the  trachea,  and  should  be  looked 
upon  as  an  indication  for  change  of  the  tube  to  one  of  different  length 
(Parker).  Or  the  dyspnoea  may  be  due  to  adhesions  in  the  larynx  or 
possibly  paralysis  of  the  laryngeal  muscles,  inflammatory  softening  of  the 
trachea,  or  swelling  of  the  mucous  membrane. 

Where,  then,  the  tube  cannot  be  removed  entirely  after  the  fifth  day,  the 
metal  one  should  be  replaced  by  a  rubber  one,  or  frequent  changes  made  in 
the  lengtli  of  the  tube,  and  daily  attempts  made  to  dispense  with  the  tube 
altogether.     Should  the  obstruction  continue,  search  must  be  made  for  its 

1  Archives  of  Pcediatrics,  January  1884. 
-  St.  Bart/iolomno's  Reports,  1885. 


344  Diseases  of  the  Respiratory  Apparatus 

cause  ;  the  most  common  is  the  granulation  mass  which  may  sometimes 
be  seen  on  using  the  dilator  and  be  removed,  its  base  being  touched  with 
nitrate  of  silver.  Failing  this,  it  is  well  to  wait  a  week  or  so  and  allow  the 
child  to  regain  strength  ;  it  should  then  be  examined  under  an  anaesthetic, 
and,  failing  the  finding  of  granulations  or  other  obvious  cause,  a  flexible 
probe  should  be  passed  up  through  the  glottis  from  below  and  a  piece  of 
silk  carrying  a  small  sponge  be  attached  to  it  ;  the  probe  should  then  be 
drawn  out  through  the  mouth,  and  the  sponge  carried  through  the  larynx 
sweeps  it  out,  breaks  down  any  adhesions,  and  clears  away  mucus  or  any 
granulations  there  may  be.  We  have  by  this  means  succeeded  in  restoring 
the  breathing  powers  after  many  attempts  at  doing  without  the  tube  for  a 
long  time. 

The  dangers,  then,  of  the  too  prolonged  retention  of  the  tube  are  the 
possible  development  of  granulation  masses  and  ulceration  of  the  trachea 
which  may  either  lead  to  haemorrhage  from  perforating  the  innominate 
artery  or  vein,  or  to  subsequent  tracheal  stenosis  from  cicatricial  stricture. 
Roger,  in  1 859,  and  Heilly  {Le  Progres Medical,  November  29,  1 884),  estimated 
that  in  about  one  in  five  of  the  cases  of  tracheotomy  there  is  ulceration  of  the 
trachea,  but  these  results  are  from  post-mortem  observations.  The  ulcera- 
tion may  be  either  on  the  anterior  or  posterior  wall  of  the  trachea  and  gives 
rise  to  no  special  symptoms  at  the  time,  unless  some  important  vessel  is 
opened. 

Sometimes  mere  nervousness  and  fear  of  suffocation  prevent  the  removal 
of  the  tube  ;  in  such  cases  attempts  must  be  gradually  made  by  the  use  of  a 
tube  with  a  large  fenestra  to  allow  the  passage  of  air  through  the  larynx,  while 
the  external  orifice  of  the  tube  is  closed  with  the  finger  or  a  cork  for  gradu- 
ally increased  periods  of  time.  Careful  watch  must  always  be  kept  upon 
these  cases  for  fear  of  sudden  asphyxia,  which  may  come  on  after  removal 
of  the  tube,  as  soon  as  the  tracheal  orifice  becomes  small,  or  even  later  than 
this  from  growth  of  granulations  from  the  inner  surface  of  the  wound.  In 
such  cases  the  wound  may  require  to  be  reopened  and  the  tube  to  be  inserted 
afresh.  In  some  few  cases  the  tube  can  never  be  dispensed  with,  and  has  to 
be  worn  permanently ;  but  usually  some  cause  of  obstruction  can  be  found. 
Sometimes  a  tough  dense  cicatricial  membrane  forms  about  the  lower  aper- 
ture of  the  larynx  or  upper  part  of  the  trachea,  and  requires  removal  by 
enlargement  of  the  tracheotomy  opening  or  by  thyrotomy.  Intubation  with 
or  without  removal  of  cicatricial  tissue  is  effectual  in  some  cases. ^  In  any 
case  where  the  tube  has  to  be  long  retained,  great  care  must  be  taken  to 
avoid  ulceration  and  to  see  that  the  tube  is  not  corroded  ;  it  has  several 
times  happened  that  the  tube  has  dropped  off  the  shield  and  fallen  into  the 
trachea  after  long  wear. 

As  to  the  application  of  lotions  &c.  to  the  interior  of  the  trachea  after 
operation,  the  number  of  specifics  is  as  great  as  that  for  the  throat  ;  the  soda 
lotion  and  lime  water-  do,  no  doubt,  soften  the  membrane  and  mucus,  and 
allow  it  to  be  more  easily  detached ;  of  the  other  remedies  probably  the  best 
is  the  instillation  of  2  or  3  drops  of  1-2000  mercurial  solution.  The  applica- 
tions may  be  made  with  a  brush  or  spray  producer,  or  a  drop  or  two  may  be 

1    Vide  Pitts  and  Brook,  Lancet,  January  10,  1891. 

-  Lime  water  is  soon  rendered  inefficient  by  the  CO2  of  the  expired  air. 


Diphtheria  of  the  Air  Passages  345 

instilled  through  the  tube  from  time  to  time.  Smearing  the  tube  each  time 
it  is  replaced  with  iodoform  ointment  is  a  good  plan.  The  wound  should  be 
swabbed  over  daily  with  a  solution  of  perchloride  of  mercury  (1-2000),  and 
then  powdered  with  equal  parts  of  iodoform  and  boric  acid. 

After  the  operation  the  child  is  greatly  relieved,  usually  falls  asleep,  and  all 
goes  on  well  for  twenty-four  or  forty-eight  hours,  and  then  in  fatal  cases  death 
occurs,  often  suddenly.  This  sudden  death  may  be  due  to  various  causes  ; 
blocking  of  the  tube  with  detached  membrane  or  mucus,  extension  downwards 
of  the  disease,  possibly  irritation  of  the  vagus  (Parker),  simple  asthenia  or 
poisoning  by  the  disease,  pneumonia,  or  cardiac  failure. 

There  is  no  doubt  that  the  majority  of  cases  of  tracheotomy  for  diphtheria 
die  ;  the  mortality  varies  with  the  epidemic  and  with  the  operator,  for  neces- 
sarily the  surgeon  who  will  only  operate  in  the  most  favourable  cases  will 
have  a  lower  mortality  than  he  who  gives  a  chance  of  relief  to  less  hopeful  cases 
as  well.  Hence  statistics  are  of  no  value.  It  is,  however,  roughly  true  that 
a  large  proportion  of  the  cases  described  as  croup  recover  after  tracheotomy, 
while  those  classed  as  diphtheria  mostly  die. 

Age  has  a  very  important  bearing  on  the  success  of  the  operation. 
Children  under  2  years  comparatively  seldom  recover  ;  ^  the  feebleness  of 
the  child,  the  increased  difficulty  of  the  operation  and  of  the  subsequent 
management,  all  make  the  prospect  at  this  age  worse.  R.  W.  Parker  has 
had  50  per  cent,  of  successes  in  his  own  practice,  but  this  must  be  considered 
far  better  than  the  average  result.'^     See  also  p.  336. 

Archambault,  in  the  Paris  Children's  Hospital,  gives  the  following  table 
of  tracheotomy  cases  : 

Cases  Recoveries 

1-3  years  ......     976  104 


3-4 

4-5 

5-6 

above  6 


820  175 

736  174 

497  148 

547  198 


Jacobson  says  one  case  of  recovery  in  three  or  four  is  a  good  average 
('  Operations  of  Surgery,'  1897,  3rd  Ed.). 

For  the  general  management  and  feeding  of  diphtheria  cases,  as  well  as 
for  the  treatment  of  the  fauces  and  mouth,  see  DIPHTHERIA. 

Apart  from  diphtheria  or  croup,  tracheotomy  may  have  to  be  considered 
in  cases  oi  scalds  of  the  glottis,  usually  the  result  of  an  attempt  to  drink  from 
the  spout  of  a  tea  kettle.  In  such  cases,  as  Sir  S.  Wilks  has  shown,  a  false 
membrane  may  be  produced  exactly  like  that  of  diphtheria.^  The  symptoms 
usually  come  on  immediately,  and  in  slight  cases  soon  subside  if  the  child 
is  kept  in  bed  in  a  warm  moist  atmosphere.  Sudden  spasm,  bronchitis,  and 
pneumonia,  and  the  formation  of  false  membrane  are  the  chief  dangers. 

1  But  Lindner,  Jahrhiichf.  Kinderheilk.  B.  xx.  H.  2,  records  38  per  cent,  of  successes 
for  '  croup  and  diphtheria,'  and  most  of  the  successes  were  in  the  second  year  of  life  ;  and 
Chaym,  Archiv.  f.  Khiderkeilk.  B.  iv.  H.  11,  12,  has  collected  220  successful  cases  under 
2  years  ;  the  youngest  cases  are  6  weeks  and  9  weeks  respectively ;  the  latter,  however, 
was  for  post-pharyngeal  abscess. — Berlitier  klin.   IVoch.  1880. 

-  Edin.  Med.  Jour.  Novembei-  1888. 

^  Guy's  Reports,  i860,  and  Bryant  in  the  same  number. 


346  Diseases  of  the  Respi7^atory  Apparatus 

The  treatment  of  such  cases  consists  in  keeping  the  child  in  a  tracheotomy 
tent  and  giving  antimony  or  an  emetic.  If  the  child  is  steadily  getting 
worse,  tracheotomy  should  be  performed.  The  tube  may  be  removed 
usually  on  the  third  to  eighth  day.  Scarification  is  often  recommended,  but 
is  more  easy  to  write  about  than  to  perform. 

Foreign  bodies  often  find  their  way  into  the  air  passages  of  children. 
A  bead,  or  grain  of  maize,  or  a  plum  stone,  or  other  foreign  body  is  held 
in  the  child's  mouth,  and  a  sudden  inspiration  may  cause  it  to  pass  into  the 
larynx.  The  body  may  lodge  in  the  upper  opening  of  the  larynx  or 
in  the  rima,  or  may  pass  into  the  trachea  or  either  bronchus,  usually  the 
right. 

Parker  records  a  case  in  which  a  caseous  lymphatic  gland  ulcerated  its 
way  into  and  blocked  the  trachea.^ 

If  the  body  is  in  the  larynx  there  will  be  dyspnoea  and  more  or  less  loss  of 
voice,  with  hoarse  or  ringing  cough,  and  if  in  the  trachea  possibly  a  loose 
rattling"  sound  may  be  heard  on  listening  over  the  front  of  the  neck,  indicating 
the  movement  of  the  body  in  the  trachea.  If  the  substance  is  lodged  in  the 
bronchus  there  will  be  impaired  breath  sounds,  and  possibly  collapse  of  the 
lung  on  the  same  side. 

If  the  history  is  clear,  tracheotomy  should  at  once  be  performed,  as  sudden 
asphyxia  often  comes  on  quite  unexpectedly  ;  hence  urgent  symptoms  should 
not  be  waited  for.  The  opening  in  the  trachea  should  be  free,  and  the  edges 
should  be  held  apart  to  allow  of  the  ready  expulsion  of  the  body,  which  is 
often  blown  out  at  once.  If  this  does  not  occur,  the  larynx  should  be  searched, 
a  probe  being  passed  in  from  below  and  the  finger  made  to  explore  the 
throat  from  the  mouth.  If  the  body  is  lodged  below  the  opening,  the  child 
should  be  inverted  and  shaken,  and  if  this  is  unsuccessful  an  attempt  should 
be  made  to  extract  the  substance  with  forceps  or  a  brush  passed  down  the 
trachea.  Bronchitis  and  pneumonia  usually  speedily  result  if  the  foreign 
bod)'  is  not  removed. 

Should  the  attempt  at  removal  fail,  if  the  body  is  in  the  larynx  and  cannot 
be  pushed  up  into  the  mouth  or  removed  from  below,  it  is  probably  better 
to  follow  Holmes's  advice  and  divide  partially  or  wholly  the  thyroid  cartilage 
so  as  to  expose  and  remove  the  impacted  mass  ;  the  operation  is  likely  to  do 
less  harm  than  the  retention  of  the  foreign  material.  If  the  substance  is 
lodged  in  the  lungs,  it  may  possibly  be  removed  at  a  second  attempt  or 
may  become  loosened  and  coughed  up  ;  occasionally  such  bodies  ulcerate 
their  way  out  and  may  even  reach  the  surface  of  the  chest.  In  other  cases 
death  results  from  pneumonia  or  pulmonary  abscess. 

Certain  other  conditions  may  demand  tracheotomy  in  children — congenital 
syphilitic  laryngitis,  chronic  simple  laryngitis,  papilloma,  or,  as  already  men- 
tioned, pressure  of  pharyngeal  abscesses. 

Intubation  of  tbe  larynx  has  been  of  late  years  practised  by  O'Uwyer, 
Waxham,  and  others,  chiefly  in  America,  as  a  substitute  for  tracheotomy.  It 
has  been  urged  in  its  favour  that  it  is  a  less  severe  measure  than  that  opera- 
tion, and  is  likely  to  be  permitted  by  friends  when  a  cutting  operation  is  re- 
fused ;  that  it  does  not  prevent  opening  the  trachea  later,  should  that  become 
necessary,  and  that  it  is  efficient,  while  it  does  not  expose  a  raw  surface  to 
1  Brit.  Med.  Jour.  October  i,  1890. 


Intubation  347 

the  diphtheritic  jjoison  nor  allow  unwanned  air  to  reach  the  lungs.  A  special 
set  of  instruments  is  recjuired  for  this  plan.  From  20  to  30  per  cent.'  of 
successful  results  have  been  obtained,  but  several  drawbacks  to  its  use  are 
admitted,  such  as  the  difficulty  of  the  manipulation,  the  liability  to  displace- 
ment of  the  tube,  and  its  obstruction  by  membrane.  Our  experience  of  the 
operation  has  shown  that  a  little  practice  is  recjuired  to  learn  readily  to  intro- 
duce the  tube  :  it  is  much  more  difficult  to  remove  the  tube  from  the  larynx. 


Fig.  64. — O'Dwyer's  Intubation  Apparatus.     The  figure  shows  the  '  introducer  '  with  a  tube 
fitted  on.     A  separate  tube  is  also  shown. 

.Several  improvements  have  been  made  in  the  apparatus,  and  the  method  has 
no  doubt  a  considerable  though  limited  field  of  usefulness.  Intubation, 
as  sugg'ested  by  Symonds,  is  certainly  useful  in  some  cases  where  after 
tracheotomy  there  is  a  difficulty  in  getting  rid  of  the  tube.'- 

In  one  mstance  in  which  we  performed  intubation  upon  a  living  child  the 
result  was  disastrous  ;  a  portion  of  the  membrane  was  pushed  down  before 
the  tube,  and  the  child  instantly  choked  :  it  was  only  by  immediate  tracheo- 
tomy and    the  use  of  artificial    respiration    that   breathing    was    restored. 


Fig.  65. — O'Dwyer's  Extractor.     The  jointed  beak  fits  into  the  tube  and  holds  it  firmlj^  when 
the  lever  is  depressed  by  the  thumb  of  the  operator. 

Others  have  had  similar  experience.  We  have  had  some  experience  of  the 
method  in  various  forms  of  laryngeal  obstruction,  and  have  not  been  led  to 
take  a  very  favourable  view  of  its  suitability  for  cases  of  diphtheria  where 

1    Vide  Wa.xham,  Brit.  Med.  Join-.  September  29,  1888. 

-  For  further  details  we  must  refer  to  the  Medical  Chronicle  for  1887,  where  abstracts 
of  numerous  papers  on  the  subject  will  be  found  ;  also  to  the  Archives  of  Pcediatrics,  1887, 
and  \^'axham's  paper  already  referred  to,  and  to  the  Appendix  of  the  present  work  ; 
also  to  Ball's  Book  on  Intubation,  and  Northrup,  Brit.  Med.  Jour.  December  29,  1894. 


34^  Diseases  of  the  Respiratory  Apparatus 

false  membrane  in  any  quantity  is  present.  Of  eleven  cases  of  intubation 
under  our  care,  in  three  success  followed,  in  three  tracheotomy  was 
subsequently  successfully  performed,  and  in  four  instances  the  children  died 
in  spite  of  tracheotomy.  The  operation  appears  best  adapted  for  cases 
where  there  is  little  or  no  false  membrane — i.e.  certain  types  of  acute 
laryngitis,  the  less  severe  forms  of  diphtheria,  where  tracheotomy  is  for  any 
reason  undesirable,  and  for  use  in  cases  where  mechanical  obstruction 
remains  after  tracheotomy,  or  results  from  cicatricial  contraction  in  the 
larynx.  It  is  certainly  unsuitable  for  bronchitic  and  pneumonic  patients. 
Recently  a  special  pattern  of  short  wide  tubes  has  been  used  for  cases  where 
there  is  much  loose  membrane  or  discharge.-^ 

Lovett,'-^  from  a  study  of  858  cases  operated  upon  at  the  Boston  City 
Hospital  either  by  tracheotomy  or  intubation,  concludes  :  '  In  general 
I  would  be  glad  to  advocate  the  performance  of  tracheotomy  instead  of 
intubation  in  most  cases  of  severe  laryngeal  diphtheria,  except  in  the  cases 
of  children  under  two  years,  when  intubation  is  to  be  performed.' 

The  apparatus  used  for  intubation,  and  figured  above,  consists  of  a 
special  tube  with  an  '  introducer  '  and  '  extractor.'  The  child  should  be 
swathed  in  a  blanket  and  held  upright  in  the  nurse's  arms.  The  mouth  is 
held  open  by  a  gag,  a  tube  of  proper  size  selected,  threaded,  and  its  pilot 
screwed  on  to  the  mtroducer  ;  the  left  forefinger  passed  to  the  back  of  the 
throat  pulls  forward  the  epiglottis  and  serves  as  guide  to  the  tube.  Any 
difficulty  in  introducing  the  tube  may,  we  have  found,  be  got  over  by  waiting 
for  an  inspiratory  effort  on  the  part  of  the  patient  and  then  slipping  in  the 
tube  :  this  is  a  little  practical  point  of  much  value.  As  soon  as  the  tube  is 
in  the  larynx  the  introducer  is  withdrawn  with  the  pilot,  and  if  the  tube  is  in 
position  the  thread  may  be  also  withdrawn.  We  are  of  opinion  that  it  is, 
however,  much  better  to  leave  the  thread  in  the  tube  to  facilitate  extraction  ; 
usually  it  sets  up  little  or  no  irritation.  The  tube  is  then  left  in  position  for 
a  time  varying  from  a  few  hours  to  two  or  three  days,  according"  to  the 
circumstances  of  the  case.  If  left  too  long  it  may  cause  ulceration  of  the 
larynx  or  trachea.^  To  remove  it  an  antesthetic  may  or  may  not  be  given, 
the  extractor  is  introduced  into  the  opening  of  the  tube,  which  is  then  with- 
drawn. If  too  small  a  tube  is  used,  it  may  slip  into  the  trachea.  ,  Without 
practice  the  tube  is  apt  to  be  passed  into  the  oesophagus. 

After  the  introduction  of  the  tube,  relief,  though  not  necessarily  imme- 
diate, is  usually  speedy.  There  is  sometimes  difficulty  in  feeding,  from  a 
tendency  for  fluids  to  pass  into  the  trachea.  If  this  difficulty  occurs  it  can 
be  met  by  feeding  the  child  with  its  head  hanging  far  back  or  by  giving 
semi-solid  food. 

Chronic  laryng'itis. — Both  infants  and  older  children  suffer  from  chronic 
hoarseness,  with  occasionally  acute  or  subacute  exacerbations,  with  croupy 
symptoms.  Such  cases  may  take  their  origin  in  a  past  attack  or  attacks  of 
subacute  laryngitis,  a  certain  amount  of  thickening  being  left  behind.  Other 
cases  are  apparently  syphilitic,  especially  in  infants.  Tubercular  laryngitis 
may  also  occur,  but  it  is  certainly  uncommon.  The  larynx  is  also  sometimes 
affected  in  cases  of  chronic  pharyngitis  where  the  tonsils  are  enlarged  and 
1  Northrup,  Bi'it.  Med.  Jour.  December  29,  1894. 

2  The  Medical  A' ews,  August  27,  1892.  ^  Carr,  Lancet,  March  28,  1891. 


Papilloma  of  Larynx 


349 


perhaps  post-nasal  j^rowths  also  exist.  If  the  symptoms  do  not  yield  to 
astringent  applications  or  the  use  of  caustics  such  as  nitrate  of  silver,  there 
may  ho.  so  much  progressive  thickening  and  dyspnoea  that  tracheotomy 
may  be  required  ;  this  is,  however,  very  rarely  the  case. 

Papilloma  of  the  larynx  is  a  somewhat  rare  affection,  consisting  of  one 
or  more  warty  outgrowths  from  the  neighbourhood  of  the  true  vocal  cords. 
The  chief  symptoms  are  chronic 
iioarseness,  loss  of  voice,  stridulous 
l)reathing  and  croupy  cough.  Later 
tliere  may  be  intermittent  attacks 
of  dyspncea,  especially  coming  on 
at  night.  There  may  be  loud  la- 
ryngeal stridor  during  inspiration 
and  sucking  in  of  the  chest  walls, 
which  is  worse  at  some  times  than 
others.  There  may  also  be  loss  of 
pulse  during  inspiration.  Where 
laryngoscopy  is  practicable,  in- 
spection shows  the  warty  mass  or 
masses  usually  about  the  anterior 
part  of  the  glottis.  Sudden  ob- 
struction of  the  aperture  may  result 
from  spasm  set  up  by  impaction 
of  a  pendulous  growth  between  the 
cords,  or  gradual  asphyxia  may 
come  on.  A  case  has  been  re- 
ported in  a  child  as  young  as 
14  months  ;  it  is  possible  these 
growths  may  be  congenital  in  some 
instances.  In  a  case  of  our  own, 
in  a  girl  of  3^  years  there  was  a  his- 
tory of  laryngeal  stridor  from  birth. 
Three  modes  of  treatment  are 
possible — removal  of  the  growths 
by  endolaryngeal  operation,  a 
method  applicable  only  to  late 
childhood  and  adults  ;  the  second 
is  tracheotomy,  with  or  without  an 
attempt  to  remove  the  growths 
from  the  tracheotomy  wound  ;  and 
the  third  is  thyrotomy,  with  ex- 
cision of  the  warts  when  fully 
exposed.  The  last  plan,  which  is  the  simplest,  is  open  to  the  objection 
that  injury  is  likely  to  be  done  to  the  vocal  cords  and  permanent  aphonia 
may  result.  Several  successful  cases  by  Parker,  Davies-CoUey,  and  others, 
have,  however,  been  recorded.  On  the  whole,  in  this  disease,  it  is  probably 
best  to  perform  tracheotomy  and  trust  to  spontaneous  disappearance  of  the 
growths,  leaving  resort  to  thyrotomy  for  cases  in  which  long  use  of  the 
tracheotomy  tube  is  unsuccessful. 


Fig.  66. — Papilloma  of  the  laryn.\.  Girl  aged  5 
years.  The  growths  are  seen  attached  to  the 
vocal  cords,  and  are  also  present  in  the  neighbour- 
hood of  the  tracheotomy  wound.  One  or  two 
caseous  glands  are  seen  at  the  bifurcation  of  the 
trachea.  See  case.  (From  a  photograph  by 
F.  H.  Westmacott.) 


350  Diseases  of  tJie  Respwatory  Apparatus 

In  two  cases  under  treatment  at  the  Children's  Hospital  by  our  colleagues 
Dr.  Hutton  and  Mr.  Collier,  and  by  ourselves,  repeated  operations  were 
required  both  in  the  shape  of  thyrotomy  and  of  scraping  out  the  growths 
through  the  laryngeal  apeiture.  The  tendency  to  recurrence  was  very 
marked  indeed,  and  more  than  once  the  windpipe  had  to  be  reopened  to 
prevent  suffocation  after  the  children  had  appeared  to  be  convalescent.  In 
both  cases  it  was  found  impossible  to  dispense  with  a  tube.  The  growths 
sprang  from  all  parts  of  the  interior  of  the  larynx  and  upper  portion  of  the 
trachea.  Hutton^  points  out  that  cases  of  spontaneous  disappearance  of 
these  growths  have  been  recorded  after  portions  had  been  coughed  up,  as 
well  as  after  tracheotomy  without  further  operation,  and  after  an  attack  of 
one  of  the  exanthemata. 

Dr.  Railton  has  published  two  cases  in  girls  aged  3  years  and  3  months 
and  4  years  respectively  who  were  treated  by  ti^acheotomy  only.  The  former 
wore  a  soft  tube  for  45  months  and  the  latter  25  months  ;  in  both  cases  the 
warty  growths  disappeared  spontaneously.  It  must  be  borne  in  mind  that 
the  growths  are  very  apt  to  form  in  connection  wtih  the  tracheotomy  wound 
on  the  inner  surface  of  the  trachea  (see  fig.  66). 

The  following  case  unfortunately  ended  fatally  by  sudden  laryngeal 
obstruction  : 

Papilloma  of  larynx. — MaryC,  set.  5  years,  was  admitted  into  Blackburn  Infirmary 
under  Dr.  Hunt  with  severe  laryngeal  obstruction,  for  which  tracheotomy  had  to  be  per- 
formed March  1897.  She  had  suffered  from  attacks  of  dyspncea  and  hoarseness  for  some 
time  before.  Several  attempts  were  made  subsequently  to  dispense  with  the  tube,  but 
without  success.  She  was  admitted  to  the  Children's  Hospital  November  20,  1897. 
During  her  stay  in  hospital,  the  tube  was  removed  on  several  occasions  and  a  probe  passed 
upwards  into  the  mouth  ;  the  probe  passed  readily  without  meeting  with  any  obstruction. 
Examination  with  laryngoscope  was  very  difficult  and  without  a  definite  result.  The  tube 
was  removed  at  first  for  short  intervals,  and  later  removed  altogether.  She  breathed  easily 
at  night,  but  at  times  had  attacks  of  dyspnoea,  her  voice  was  hoarse  and  whispering.  Her 
temperature  latterly  varied  from  97°-ioo°,  and  she  lost  flesh.  She  had  an  attack  of  urgent 
dyspncea  December  20,  1897,  and  died  suddenly.  At  the  post-mortem,  there  was  early 
tuberculosis  at  the  apex  of  the  right  lung  and  caseous  mediastinal  glands.  There  was  a 
mass  of  papillomata  on  the  vocal  cords,  and  also  at  the  site  of  the  tracheotomy  wound 
(see  fig.  66.) 

In  this  case  it  was  no  doubt  unwise  to  remove  the  tracheotomy  tube  ;  it 
would  have  been  better  to  have  allowed  her  to  wear  a  soft  rubber  tube  for 
many  months,  or  years  if  necessary,  taking  care  to  remove  as  far  as  possible 
the  warty  growths  which  form  inside  the  trachea  at  the  seat  of  the  tracheo- 
tomy wound.  The  fact  that  the  girl  was  suffering  from  an  early  stage  of 
tuberculosis  of  the  bronchial  glands  and  lung,  suggests  the  possibility  of  a 
hospital  infection  with  tuberculosis  through  the  tube.  Presumably  there  is 
more  risk  of  this  happening  to  the  wearer  of  a  tracheotomy  tube,  than  when 
breathing  in  the  normal  way  through  the  mouth  and  nose. 

1   Hutton,  Med.   Chron.  vol.  i.  N.s.  1894. 


35f 


CHAPTER    XVII 

DISEASES    OF   THE    RESPIRATORY    APPARATUS— 6WZ/z>2Z/^<^ 

Bronchitis  and  Catarrh 

Catarrh  of  the  bronchial  tubes  is  a  common  affection  at  all  periods  of  life 
and  in  every  social  grade,  but  it  is  in  early  childhood  that  it  is  perhaps  the 
most  common,  and  it  is  at  this  period  that  it  assumes  the  greatest  importance 
from  the  diseases  which  are  liable  to  follow  in  its  train.  In  old  age,  when 
the  lungs  are  damaged  by  emphysema,  and  the  chest  walls  have  lost  their 
elasticity,  bronchitis  is  apt  to  be  a  serious  and  often  fatal  disease  ;  but  not 
less  so  is  it  in  the  very  young,  in  whom  the  chest  walls  are  alike  wanting  in 
elasticity  and  rigidity,  the  bronchial  tubes  easily  collapse,  and  the  lungs 
very  readily  join  in  the  inflammation.  The  greatest  liability  appears  to  occur 
during  the  first  two  years  of  life  ;  certainly  at  this  age  it  is  most  fatal.  Ex- 
posure to  cold  is  in  a  large  number  of  cases  the  exciting  cause  ;  climatic 
influences  are  seen,  especially  in  late  autumn  or  early  winter,  in  the  large 
number  of  cases  of  chest  affections  which  occur  at  this  period.  That  the 
larger  number  of  cases  should  occur  among  the  lower  and  worst-housed 
class  is  only  what  is  to  be  expected,  inasmuch  as  the  lives  of  the  infants  and 
children  are  spent  either  in  the  foul  and  stuffy  atmosphere  of  an  overcrowded 
and  ill-ventilated  house,  or  they  are  exposed,  imperfectly  clad,  to  all  sorts  of 
weather  in  the  streets. 

The  predisposing  causes  are  many  ;  some  children  seem  to  inherit  a 
tendency  to  bronchial  catarrh,  and,  in  spite  of  the  greatest  care  and  the 
most  constant  'coddling,'  suffer  every  few  months,  perhaps  for  the  whole  of 
the  winter,  from  bronchial  catarrh  or  severe  colds,  which  pass  into  bronchitis 
with  the  greatest  readiness  ;  dentition,  rickets,  measles,  whooping  cough, 
intestinal  catarrh  frequently  play  an  important  part  in  the  production  of  a 
bronchitis.  During  the  time  that  a  tooth  is  being  cut  children  seem  very 
apt  to  suffer  from  catarrh,  which  in  the  winter  aftects  the  bronchial  tubes 
and  in  summer  the  intestines.  Pressure  of  the  tooth  on  the  gums  seems  to 
act  reflexly  in  producing  a  catarrh,  sometimes  with  more  or  less  spasm,  as 
the  child  becomes  wheezy  at  night,  sibilus  being  heard  all  over  the  chest, 
while  in  the  morning  it  will  be  perfectly  well.  This  may  happen  several 
nights  in  succession.  Rickety  children  are  specially  prone  to  suffer  from 
bronchial  affections,  and  in  them  it  is  especially  serious  on  account  of  the 
softness  of  the  ribs,  and  the  weakness  of  the  muscles  of  respiration,  resulting 
in  deformed  chests  and  collapsed  lung. 

Sy77iptoins  and  Course. — The  attack  is  often  preceded  by  a  cold  in  the 


352  Diseases  of  the  Respiratory  Appai-atus 

head,  the  infant  sneezes,  its  nose  runs,  and  it  begins  to  cough.  If  the 
bronchial  catarrh  which  follows  is  mild,  and  the  catarrh  does  not  extend 
beyond  the  trachea  and  large  bronchi,  the  general  symptoms  are  slight  : 
there  is  no  distress,  no  dyspnoea,  only  a  troublesome  cough,  perhaps  some 
wheezing  during  respiration  and  a  slightly  elevated  temperature  at  night. 
In  the  more  severe  attacks;  in  which  the  smaller  bronchial  tubes  are  involved, 
their  mucous  membrane  being"  swollen  and  the  secretion  thick  and  viscid, 
dyspnoea  from  obstruction  to  the  air  entering  the  lungs  will  be  present. 
The  pulse  is  hard  and  accelerated,  the  number  of  respirations  increased 
according  to  the  amount  of  obstruction,  the  ala;  nasi  working,  the  skin 
hot,  and  the  infant  restless  and  thirsty.  On  placing  the  ear  to  the  chest,  dry 
hissing  or  snoring  sounds  will  be  heard  during  inspiration,  as  the  air  rushes 
through  the  pulmonary  divisions  of  the  bronchi,  in  the  severer  cases  entirely 
obscuring  the  respiratory  murmur.  In  the  milder  attacks  rhonchi  will  only 
be  heard  with  some  respiratory  movements,  being  more  especially  heard  at 
the  roots  of  the  lungs. 

In  infants  and  young  children,  especially  if  their  ribs  are  softened  in 
consequence  of  rickets,  there  is  recession  of  the  chest  walls,  chiefly  at  the 
epigastrium  and  lower  lateral  region  of  the  chest,  due  to  the  imperfect  fiUing 
of  the  lungs,  the  chest  wall  falling  in  in  place  of  the  lungs  expanding.  In  a 
later  stage  the  sibilant  or  rhonchial  sounds  become  mixed  with  moist  rales  : 
these  are  not  distinctly  and  sharply  crepitant,  as  of  bubbles  passing  through 
thin  fluid,  but  indistinct  bubbling  sounds  as  of  air  forced  through  thick 
tenacious  mucus.  The  moist  sounds  succeeding  the  dry,  point  to  a  freer 
secretion  of  mucus  from  the  hitherto  swollen  and  congested  mucous  mem- 
brane. In  some  cases  in  infants  mucous  bubbling  rales  are  heard  from  the 
first.  If  convalescence  is  quickly  established,  the  abnormal  sounds  are 
gradually  replaced  by  the  normal  respiratory  murmur,  though  rhonchi  or 
rales  may  be  heard  for  some  clays  or  weeks.  Percussion  of  the  chest  walls 
during  an  attack  of  uncomplicated  bronchitis  shows  the  resonance  normal, 
although  perhaps  there  may  be  some  hyper-resonance  at  the  sub-clavicular 
regions  from  the  presence  of  more  or  less  emphysema. 

In  most  attacks  of  bronchitis  there  is  usually  more  or  less  disturbance 
of  the  digestive  organs.  The  bowels  may  be  confined  and  distended  with 
flatulence,  the  tongue  is  coated,  and  there  is  often  more  or  less  vomiting. 

The  fever  in  uncomplicated  cases  is  never  high  ;  there  may  be  an  even- 
ing rise  of  a  degree  or  two,  while  the  morning  temperature  may  be  normal 
or  subnormal,  especially  in  weakly  children.  The  cough,  which  in  the  early 
stages  is  hard,  in  the  later  stages  becomes  looser,  mucus  is  coughed  up  into 
the  pharynx  and  then  quickly  swallowed,  unless  extracted  by  means  of 
the  nurse's  finger.  Children  under  five  years  rarely  expectorate — mucus  is 
coughed  up,  but  they  have  not  the  sense  to  spit  it  out. 

An  attack  of  bronchitis  usually  lasts  a  week  or  ten  days  and  ends  in 
recovery,  leaving  the  child  subject  to  a  second  attack. 

Complications. — Bronchitis  in  infants  and  young  children  is  frequently 
accompanied  by  one  or  more  complications,  the  commonest  being  collapse 
of  the  lung,  catarrhal  pneumonia,  bronchiectasis,  and  emphysema.  In  a  fatal 
case  it  is  almost  certain  that  one,  or  more  often  all  four;  of  these  complications 
will  be  found. 


Bronchitis  and  Catarrh  -i^z^T^ 

Collapse  of  Ziung:. — During  an  attack  of  bronchitis  or  bronchial  catarrh 
it  is  not  uncommon  to  note  that  the  respiratory  murmur  is  weak  or  absent 
over  a  portion  of  lung — as,  for  instance,  one  or  other  base  ;  then  perhaps  after 
a  vigorous  cough  a  plug  of  mucus  is  dislodged  from  a  large  bronchus  and 
the  breath  sounds,  with  perhaps  some  loose  rales,  are  heard  o\er  the  same 
area.  At  other  times  the  breath  sounds  are  absent,  and  by  the  next  day  the 
ordinary  respiratory  murmur  will  again  be  heard.  In  this  case  a  plug  of 
thick  mucus  lodged  in  one  of  the  larger  divisions  of  the  pulmonary  bronchi 
prevents  the  ingress  and  egress  of  the  air  from  the  lung,  but  is  expelled 
and  coughed  up  by  an  extra  effort. 

If,  however,  thick  mucus  is  drawn  into  the  smaller  bronchi,  perhaps 
filling  up  a  series  of  small  branches,  the  most  powerful  expiratory  effort  the 
child  can  make  fails  to  clear  the  occluded  bronchi,  especially  when  the  re- 
spiratory muscles  are  weak  and  the  ribs  are  soft  and  easily  bend.  Two 
things  are  now  certain  to  happen — the  lung  supplied  by  the  occluded  bronchi 
collapses  and  more  or  less  dilatation  of  the  bronchial  tubes  and  emphysema 
of  the  neighbouring  lung  occurs,  unless  the  chest  walls  fall  in  to  take  the 
room  of  the  collapsed  lung.  The  lung  collapses  in  consequence  of  the 
absorption  of  the  imprisoned  air,  the  air  entering  the  blood-vessels,  as  shown 
by  the  experiments  of  Lichtheim.  It  is  clear  that  this  collapse  of  lung  and 
vicarious  emphysema  at  least  temporarily  damages  the  lung,  and  if  this 
should  occur  to  any  great  extent  in  acute  bronchitis,  it  adds  considerably  to 
the  danger  of  death  by  asphyxia. 

The  symptoms  to  which  collapse  gives  rise  are  not  always  very  definite, 
and  unless  tolerably  extensive  there  may  be  no  sign  of  its  presence.  In 
some  cases  it  may  supervene  suddenly,  possibly  by  the  sucking  in  of  mucus 
which  has  accumulated  in  the  trachea  during  sleep  into  the  bronchial  tubes, 
the  dyspnoea  becoming  urgent,  the  child's  lips  blue  ;  it  rolls  about  in  its  cot 
struggling  for  breath,  and  convulsions  come  on  which  perhaps  prove  fatal. 
In  other  cases,  while  the  symptoms  may  be  alarming  for  the  time,  they 
quickly  pass  away,  a  result  due  to  the  mucus  being  expelled.  If  the  collapse 
is  scattered  in  patches  throughout  the  lung,  especially  if  accompanied  by 
emphysema,  it  will  be  impossible  to  detect  it  by  any  physical  signs  ;  there 
may  be  hyper-resonance  due  to  the  emphysema,  weak  breath  sounds,  and 
perhaps  some  moist  rales.  If  any  extent  of  lung  is  involved,  as  part  of  an 
apex  or  base,  there  will  be  some  loss  of  resonance,  but  this  is  rarely  well 
marked  unless  some  broncho-pneumonia  be  associated  with  it,  a  pneumonic 
patch  and  a  collapsed  patch  lying  side  by  side.  The  respiratory  murmur 
over  the  collapsed  patch  is  weak,  and  rhonchus  or  moist  sounds  may  be 
heard.  In  some  cases  there  appears  to  be  a  mixed  condition  of  collapse 
with  much  congestion  of  the  vessels  and  oedema,  or  possibly,  as  some  authors 
believe,  the  collapsed  lung  becomes  the  seat  of  a  low  form  of  pneumonia, 
leucocytes  and  epithelioid  cells  being  present  in  the  air  sacs. 

Sronctaiectasis  and  Emphysema. — Dilatation  of  the  bronchi  frequently 
takes  place  during  acute  bronchitis,  the  walls  of  the  medium-sized  and  small 
bronchi  being  thin  and  their  calibre  increased,  a  result  no  doubt  due  to  in- 
flammatory softening  of  their  walls.  Emphysema  is  also  constantly  present 
in  association  with  dilated  bronchial  tubes.  The  chest  walls  during  an  acute 
attack  assume  the  position  of  inspiration,  and,  particularly  the  infraclavicular 

A  .\ 


354 


Diseases  of  tJie  Respiratory  Apparatus 


regions,  become  hyper-resonant,  while  the  expiratory  murmur  is  prolonged. 
As  already  remarked,  compensatory  emphysema  is  constantly  present  in 
association  with  broncho-pneumonia  and  collapse.  Bronchiectasis  takes  place 
in  association  with  chronic  pleurisy  and  fibroid  conditions  of  lung. 

Chronic  Broncbitis  and  Sronchiectasis 

Children  and  infants,  like  adults,  suffer  from  chronic  bronchial  catarrh  ; 
they  recover  slowly,  and  then  perhaps  within  a  few  weeks  another  attack 
supervenes.  Some  children  show  such  a  tendency  to  these  attacks  that  they 
have  to  be  kept  prisoners  almost  all  the  winter,  as  exposure  to  even  slight 
cold  is  sufficient  to  lay  them  by  for  weeks.     Frequent  and  long-continued 


■BBBBBBiSBBB&SBi7iSiSS'ffiHBii 


IIMI 

■WIIHIMI 


■IW/I 

iini 


tFig.  67. — Tt 


iperature  Chart  of  a  case  of  Bronchitis  with  disseminated  patches  of  Pneumonia. 
Boy  of  5  years.     Recovery. 


attacks  of  bronchitis  are  certain  sooner  or  later  to  produce  emphysema,, 
dilated  bronchial  tubes,  and  dilatation  of  the  right  side  of  the  heart  and  the 
veins  which  empty  into  it.  Such  children  present  a  typical  picture  ;  they 
are  mostly  thin,  with  rounded  drooping  shoulders,  barrel-shaped  chests, 
enlarged  superficial  jugular  veins  and  often  injected  capillaries  on  the  cheeks 
In  some  of  these  more  or  less  dulness  may  be  detected  at  one  base  or  another,, 
and  they  constantly  cough  up  large  quantities  of  very  foul  mucus.  Such  cases 
are  anything  but  welcome  inmates  in  a  ward  on  account  of  their  extremely 
foetid  expectoration.  They  are  very  chronic  and  not  much  amenable  tO' 
treatment.  We  have  attempted  external  drainage  of  the  dilated  bronchial 
tube,  but  have  not  m.et  with  much  success,  as  the  patient  gradually  sank. 
In  the  milder  cases  such  children  with  care  improve  greatly,  and  frequently 


Chronic  Bronchitis — BroncJio-pneumonia  355 

by  puberty  lose  their  tendency  to  bronchial  troubles,  and  grow  up,  if  not 
strong",  at  least  not  with  impaired  health.  On  the  other  hand,  there  is  always 
the  risk  of  an  intercurrent  and  perhaps  fatal  pneumonia  ;  we  have  seen 
children  of  this  class  with  marked  emphysema  come  regularly  into  hospital 
perliaps  twice  in  a  winter  with  attacks  of  croupous  pneumonia.  There  is  a 
risk  of  chronic  bronchitis  passing"  into  a  chronic  broncho-pneumonia,  the 
lung  tissue  around  the  dilated  bronchi  becoming  fibroid  and  indurated. 
There  is  also  the  risk  of  tuberculosis,  but  we  have  not  often  been  able  to 
trace  a  connection  between  chronic  bronchitis  and  tubei'culosis,  though  those 
suffering  from  chronic  bronchitis  are  often  mistaken  for  phthisical  subjects. 

Broncho-pneumonia 

In  many  cases  the  attack  begins  with  a  bronchial  catarrh  and  quickly 
passes  on  into  a  broncho-pneumonia,  the  inflammation  extending  from  the 
bronchi  into  the  air-cells.  In  other  cases  the  bronchial  symptoms  may  be 
slight  or  absent,  and  the  attack  may  closely  resemble  a  croupous  pneumonia. 
Between  these  two  types  all  gradations  may  be  met  with.  When  the  pneu- 
monia supervenes  on  bronchitis,  all  the  symptoms  become  exaggerated,  the 
child  is  restless,  the  cough  shorter  and  more  hacking,  the  skin  hot  and  dry, 
the  evening  temperature  usually  reaching  103"  or  104°  with  morning  remis- 
sions of  several  degrees,  so  that  the  fever  assumes  a  remittent  type  ;  sometimes 
there  are  evening  instead  of  morning  remissions,  the  temperature  being  at 
its  lowest  in  the  evening  ;  the  dyspnoea  is  usually  great,  the  respirations 
numbering  forty  or  fifty,  but  varying  with  the  amount  of  fever  and  extent  of 
lung  involved.  If  the  pneumonia  is  extensive,  the  face  wears  a  distressed' 
expression,  the  alas  nasi  work  vigorously,  the  child  lies  weak  and  helpless  in 
its  mother's  arms,  too  feeble  to  cry,  or  if  it  resists  examination  for  a  while  it 
is  soon  exhausted  and  passively  submits. 

An  examination  of  the  chest,  if  made  when  the  attack  is  fully  developed 
and  severe,  shows  that  the  accessory  muscles  of  respiration  are  brought  into 
play,  the  respirations  are  rapid  and  shallow,  with  recession  of  the  epigastrium 
and  intercostal  spaces.  The  percussion  note  varies  according"  to  the  position 
of  the  consolidated  lung  ;  this  may  involve  an  extended  portion  at  one  or 
both  bases,  at  an  apex,  or  be  scattered  in  patches  over  the  lungs.  To  detect 
the  pneumonic  portions  both  light  and  strong  percussion  should  be  practised, 
carefully  comparing  any  spot  where  the  resonance  appears  impaired  with 
the  opposite  side.  There  may  be  hyper-resonance,  especially  anteriorly, 
from  the  presence  of  emphysema.  A  considerable  amount  of  pneumonia 
may  exist  if  diffuse  or  patchy  without  any  definitely  impaired  resonance. 
There  is  never  complete  dulness  in  pneumonic  consolidation  unless  much 
lymph  or  some  fluid  be  present.  On  auscultation  rhonchi  are  usually  heard 
over  the  chest,  while  over  the  .pneumonic  portions  rales  of  a  consonant  or 
ringing  character  are  heard,  which  contrast  with  the  subcrepitant  rales  of 
a  simple  bronchitis,  inasmuch  as  they  are  more  intense,  from  the  fact  of 
their  travelling  to  the  ear  through  consolidated  lung.  Even  though  no 
consohdated  lung  can  be  detected  by  percussion,  the  presence  of  consonant 
intensely  ringing  rales  with  a  temperature  of  103°  or  104°  points  almost  cer- 
tainly to  pneumonia. 

A  A  2 


j:)' 


Diseases  of  the  Respiratory  Apparatus 


In  the  early  stages  the  respiratory  murmur  is  weak,  later  there  is  mostly 
well-marked  bronchial  breathing  over  the  dull  area.  If  a  fatal  result  is 
about  to  occur,  the  respirations  become  more  hurried,  the  distress  greater, 
and  the  pulse  weaker  and  weaker  ;  rales  and  rhonchus  are  heard  o^■er  the 
whole  chest,  the  heart  flags,  and  the  child  becomes  pallid  and  comatose, 
death  taking  place  with  symptoms  of  toxaemia  on  account  of  the  bronchi 
becoming  choked  and  the  lungs  consolidated.  The  temperature  usually 
falls  towards  the  close  ;  the  child  is  frequently  convoilsed.  If,  however,  the 
attack  takes  a  favourable  turn,  towards  the  end  of  the  first  week  or  earlier 
the  temperature  approaches  normal,  the  breathing  is  easier,  and  the  child. 


HEEBBBf^ll 


iagag^BgaaaaaF 

n^,lHiiHBV^IVWaMliHL.- 


Fig.  68. — Temperature  Chart  of  a  case  of  acute  Broncho-pneumonia  in  a  boy  of  ■z\  years ; 
death  fifteenth  daj-.  At  the  post-mortem  both  bases  of  lungs  showed  generalised  broncho- 
pneumonia vith  '  graines  jaunes.' 


instead  of  concentrating  his  whole  attention  on  himself,  begins  to  notice 
those  about  and  to  play  with  his  toys.  The  physical  signs  change  but 
slowly,  the  bronchial  breathing  and  rales  being  heard  perhaps  during  the 
second  or  even  the  third  week. 

While  the  above  is  the  description  of  a  typical  attack,  the  pneumonia 
may  be  of  much  less  well-marked  character.  The  child  may  seem  ill  with 
little  or  no  cough,  while  there  is  loss  of  appetite,  coated  tongue,  and  feverish- 
ness,  especially  well  marked  during  the  afternoon  or  evening.  An  examina- 
tion of  the  chest  may  at  first  yield  no  positive  result,  yet  in  a  day  it  will  be 
noted  that  there  is  a  patch  of  lung  at  the  extreme  base,  axilla,  or  near 
the  root  where  the  air  does  not  enter  well,  and  the  respiratory  murmur  is 


Broncho-pneiimo7iia 


357 


replaced  by  breathing  of  a  distinctly  bronchial  character.     In  a  few  days  or  a 
week  the  temperature  may  again  become  normal. 

Sometimes  an  attack  of  broncho-pneumonia  closely  simulates  the 
croupous  variety,  and  there  may  be  a  doubt  as  to  which  category  to  refer  it. 
The  onset  may  be  sudden,  accompanied  by  a  convulsion  or  series  of  convul- 
sions, the  temperature  may  rise  to  104°  or  105°  (see  fig.  69),  the  physical 
signs  ma\-  point  to  an  extended  portion  of  lung  being  involved,  and  only  the 
course  of  the  attack,  the  temperature 
becoming  intermittent,  and  reaching 
normal  gradually  by  lysis,  would  seem 
to  indicate  that  the  attack  is  rather 
of  the  catarrhal  than  the  croupous 
variety.  Some  cases  may  from  first 
to  last  be  open  to  doubt. 

Course. — While  broncho-pneumonia 
is  frequently  an  acute  disease,  proving 
fatal  in  a  few  days  or  a  week,  its  course 
in  many  cases  is  subacute  or  chronic, 
lasting  for  several  weeks,  or  even 
more,  and  yet  ending  in  apparently 
complete  recovery.  In  some  instances 
reco\ery  takes  place,  to  be  followed 
by  a  relapse,  the  temperature  again 
becoming  remittent  for  a  few  days  or 
a  week.  The  termination  of  the  fever 
is  nearly  always  by  lysis.  In  these 
protracted  cases  the  possibility  of  tu- 
berculosis or  a  local  empyema  must 
always  be  borne  in  mind. 

Secondary  Pneumonias. — Pneu- 
monias, mostly  of  the  broncho-pneu- 
monic form,  occur  as  complications  of 
many  diseases,  and  may  in  consequence 
be  modified  in  their  course  and  in 
the  symptoms  they  present.  Thus  a 
miliary  tuberculosis  may  give  rise 
to  an  acute  broncho-pneumonia,  which 
may  run  a  short  or  protracted  course, 
the  two  conditions  present  essentially 
modifying  each  other.  In  wboopingr 
cougb,  measles,  scarlet  fever,  diph- 
theria, enteric  fever,  pneumonia  may  supervene,  caused  by  the  specific 
micro-organism  of  the  fever,  or,  in  many  cases  at  least,  by  the  septic  organisms 
present.  While  the  pneumonia  occurring  in  these  diseases  is  usually  of  the 
broncho-pneumonic  form,  yet  it  is  mostly  fibrinous,  and  in  the  worst  cases 
exhibits  a  tendency  to  pus  formations,  so  that  small  purulent  abscesses  may 
be  found  post  mortem.  In  some  cases  a  true  croupous  pneumonia  may 
occur.  In  diphtheria  the  pneumonia  is  often  hemorrhagic,  small  patches 
of  dark  red  extra vasated  blood  being  seen  on  section  of  the  pneumonic  lung. 


Fig.  fg.  — Temperature  Chart  ot  a  case  of  acute 
lobar  Pneumonia  in  an  infant  of  9  months  ; 
death  on  third  day.  The  whole  left  lung 
except  a  small  part  of  upper  lobe,  which  was 
emphysematous,  was  solid  ;  section  of  lung 
not  so  solid  as  red  hepatisation  ;  lobules  dis- 
tinct, some  of  a  pink  and  others  Of  a  greyish 
colour. 


35 8  Diseases  of  the  Respiratory  Apparatus 

In  acute  summer  diarrhoea  a  pneumonia  is  very  apt  to  be  present  and 
add  to  the  gravity  of  the  attack  ;  in  the    cbronic  intestinal    catarrh   of 

infants  the  immediate  cause  of  death  is  frequently  an  intercurrent  attack  of 
inflammation  of  the  lungs. 

Chronic  Broncho-pneumonia. — Attacks  of  broncho-pneumonia  are  apt 
to  become  chronic  in  consequence  of  an  imperfect  clearing  up  of  the  lung 
and  the  resulting  caseous  degeneration.  Catarrhal  pneumonia  following 
measles  or  whooping  cough  is  very  apt  in  an  unhealthy  child  or  one  who 
inherits  .tubercular  tendencies  to  take  a  subacute  course  ;  a  base,  or,  less 
often,  an  apex  of  a  lung  remains  more  or  less  dull,  the  breath  sounds  are 
bronchial,  moist  sounds  are  heard,  and  the  evening  temperature  rises  to  102° 
or  103°  F.,  with  night  sweats  and  emaciation.  This  state  of  things  may  go  on 
for  weeks,  and  it  may  be  impossible  to  say  if  the  caseous  changes  are  pro- 
gressing or  not.  The  risk  in  such  cases  is  undoubtedly  that,  although  the  lung 
may  clear  up,  the  bronchial  glands  may  become  caseous,  and  a  general  tuber- 
culosis of  the  lung,  or  perhaps  tubercular  meningitis,  follow.  Most  cases  of 
chronic  broncho-pneumonia  terminate  either  in  recovery  or  tuberculosis, 
though  in  some  instances  they  run  a  very  chronic  course,  resembling  a  chronic 
phthisis  ;  the  bronchi  become  dilated,  caseous  and  fibroid  changes  occur, 
but  rarely  acute  tuberculosis.  Such  cases  during  life  are  mostly  regarded 
as  chronic  or  fibroid  phthisis  :  they  present  in  their  later  stages  the  signs 
of  consolidation  of  a  portion  of  lung  at  an  apex  or  base,  the  chest  wall  is 
probably  retracted,  there  are  bronchial  breathing,  sharp  ringing  rales, 
and  very  foetid  expectoration,  which  is  coughed  up  in  large  quantities. 
They  are  thin,  anaemic,  are  easil}^  put  out  of  breath,  have  clubbed  fingers  and 
dilated  right  hearts.  They  are  usually  very  chronic  cases.  At  the  post- 
viortem  there  are  found  dilated  bronchi  filled  with  thick,  foul  secretion, 
cheesy  nodules  around  the  bronchial  tubes,  much  fibroid  and  indurated 
lung  tissue,  and  emphysema.  In  some  cases  there  is  gangrene  of  the  lung 
before  death.  Children  liable  to  bronchitis,  or  who  suffer  from  it  in  the  chronic 
form,  require  to  be  warmly  clothed  and  protected  from  cold.  Residence  in  a 
warm  climate  and  pure  atmosphere  during  the  winter,  and  at  high  altitudes 
during  the  summer,  should  be  insisted  on  where  possible.  A  warm  house 
is  necessary  if  they  have  to  winter  in  this  climate.  Every  means  must  be 
employed  which  will  improve  their  general  health.  In  the  following  case  a 
chronic  pneumonia  was  followed  by  acute  meningitis. 

Chronic  Pneumonia.  Acute  Meningitis. — RoseS.,  aged  5  years.  Child  comes  of  a 
tubercular  family  ;  has  had  acute  pneumonia  several  times.  She  had  acute  pneumonia 
several  weeks  before  admission,  and  was  sent  to  the  seaside.  Admitted  July  7.  There 
is  dulness  on  the  left  side  behind,  extending  from  the  spine  of  the  scapula  to  the  base  ; 
over  this  area  there  is  weak  bronchial  breathing,  and  what  is  apparently  redux  crepitation. 
Temperature  101°.  No  albimien  ;  child  well  nourished,  but  pale.  Temperatiue  fell  to 
normal  during  the  next  day  or  two.  On  July  15  the  temperature  suddenly  rose  to  104°  F. 
Towards  evening  she  began  to  vomit  continuously ;  temperature  rose  to  105°  F.  ;  there 
were  some  preliminary  twitchings,  and  then  she  was  severely  convulsed.  The  convulsions 
continued  till  early  the  next  morning,  when  she  died. 

Post-7?iortet?i.- — Left  lobe  solid  ;  sinks  in  water  ;  bronchi  contain  much  purulent  secre- 
tion, and  their  walls  are  thickened  ;  excess  of  fibrous  tissue  in  the  lung,  spreading  from 
the  root.  Lung  substance  dark  red,  soft,  and  contains  some  small  cavities  size  of  peas, 
containing  thick,  almost  cheesy,  pus.     No  obvious  tubercle  anywhere.     Brain,  arachnoid 


BroiicJio-pneumonia  359 

everywhere  cloudy,  beneath  it  there  is  an  excess  of  fluid  of  a  cloudy  yellow  tint. 
Sylvian  fissures  are  matted  with  semi-purulent  lymph,  liasc  of  brain  tiiucIi  cloudy, 
swelling  beneath  arachnoid.     No  tubercle  anywhere. 

Prognosis. — Broncho-pneumonia  is  always  a  dangerous  disease,'  Ijut  more 
especially  so  in  children  under  2  years  of  age  who  are  rickety  or  weakly. 
The  prognosis  is  necessarily  serious  if  the  pneumonia  follow  any  other  dis- 
ease, as  measles,  whooping  cough,  or  summer  diarrhoea,  or  when  it  occurs  in 
scarlet  fever  through  the  e.xtension  of  the  inflammatory  process  in  the  throat. 
In  any  severe  case  the  danger  depends  upon  the  amount  of  lung  involved 
and  the  softness  of  the  chest  walls.  It  must  also  be  remembered  that  a  young- 
child  may  struggle  through  the  bronchial  affection  only  to  pass  into  a  con- 
dition of  atrophy — the  result  of  a  gastro-intestinal  catarrh.  Both  high  and 
also  very  low  temperatures  are  indicative  of  danger.  The  pneumonia  may 
become  chronic  and  tuberculosis  supervene. 

Morbid  Anatomy. — The  appearances  seen /(Jj-/  mortem  in  the  bodies  of 
children  dying  of  bronchitis  and  broncho-pneumonia  are  very  various,  and 
are  apt  to  puzzle  those  unaccustomed  to  the  autopsies  made  in  children  ;  and 
much  confusion  has  existed  in  the  past  in  reference  to  them,  especially  in 
confounding  the  various  forms  of  pneumonia  and  carnification  of  the  lung 
with  collapse.  Collapse  of  the  lung  is  mostly  patchy  in  its  distribution,  rarely 
affecting  any  continuous  extent  of  lung  or  involving  the  whole  thickness  of  a 
lung.  It  affects  the  anterior  and  inferior  edges  of  the  lungs,  especially  the 
anterior  edge  of  the  middle  lobe  of  the  right  side  and  tongue  of  the  left 
which  covers  the  heart  ;  it  is  sometimes  present  along  the  posterior  border  of 
the  lung  ;  the  collapsed  portions  are  depressed  below  the  surface,  purple  in 
colour,  and  aii'less.  Taken  between  the  finger  and  thumb,  there  is  no  sub- 
stance to  be  felt  as  in  pneumonia.  The  collapsed  portions  can  be  inflated 
through  the  bronchi.  The  collapse  is  brought  about  in  at  least  two  ways-^ 
either  from  occlusion  of  a  small  bronchus  by  thick  mucus,  the  air  being  first 
imprisoned  and  then  absorbed  by  the  capillaries,  or  by  feeble  inspiratory 
power  aided  by  obstruction  to  the  entrance  of  air,  especially  when  the  ribs 
are  soft,  as  in  rickets  ;  in  this  case  the  chest  falls  in  during  inspiration,  in- 
stead of  the  lungs  becoming  distended  ;  it  is  in  this  way  that  collapse  is  pro- 
duced along  the  anterior  edges  of  the  lung.  The  collapsed  portions  become 
oedematous  from  the  stagnation  of  the  circulation  ;  according  to  some,  they 
become  pneumonic. 

What  happens  to  the  collapsed  portions  of  lung  in  the  long  run  is  not 
clear.  In  most  cases,  apparently,  recovery  takes  place  ;  but  we  believe  in 
some  cases  fibroid  changes  are  set  up,  as  evidenced  by  those  chronic  cases  of 
bronchitis  and  dilated  tubes,  the  latter  surrounded  by  indurated  lung.  Acute 
emphysema  plays  an  important  part  in  the  acute  lung  disease  of  children. 
It  is  sometimes  produced  very  rapidly  ;  thus,  a  child  may  die  of  acute  broncho- 
pneumonia complicating  measles  in  three  or  four  days,  and  extensive  emphy- 
sema may  be  present,  no  doubt  produced  during  the  period,  and  contributing 
very  materially  to  the  fatal  result  (see  p.  353).  The  bases  of  the  lungs  are 
in  an  early  stage  of  pneumonia  and  collapse,  the  upper  lobes  are  overworked, 
the  constant  coughing  consequent  on  the  acute  bronchitis  produces  emphy- 
sema, and  the  only  remaining  normal  lung  is  thus  damaged,  and  a  fatal  result 
quickly  ensues. 


360  Diseases  of  the  Respiratory  Apparatus 

The  chief  types  found  may  be  described  shortly  in  the  following  groups  : 

1.  Acute  Bronchitis  involving- the  Smaller  Tubes,  Collapse  of  Xiun^, 
Vicarious  Emphysema. — On  opening  the  chest  the  lungs  are  found  to  be  in 
a  condition  of  deep  inspiration  ;  these  surfaces  are  studded  over  with  clusters 
of  lobules  which  are  depressed  and  purple  in  colour  (collapse),  and  with 
raised  portions  which  are  of  a  pale  pink  colour  (emphysema).  On  section, 
thick  semi-purulent  frothy  mucus  exudes  from  the  large  and  small  bronchi  ; 
the  latter  sometimes  contain  a  semi-membranous  exudation.  The  cut  surface 
of  the  lung  exudes  much  blood-stained  frothy  fluid,  due  to  congestion  of  the 
lung  ;  the  lungs  are  crepitant,  except  where  collapse  has  taken  place.  The 
large  veins  and  right  heart  are  much  engorged. 

2.  Disseminated  Broncho-pneumonia. — The  bronchial  tubes  contain 
much  frothy  fluid,  one  or  both  lungs,  especially  the  lower  lobes  posteriorly, 
have  a  semi-solid  feel,  but  crepitate,  and  perhaps  some  nodules  of  various 
sizes  may  be  felt.  The  section  exudes  much  serum,  purulent  mucus  exudes 
from  the  small  bronchi,  the  cut  surface  of  the  lung  has  a  mottled  appearance, 
caused  by  clusters  of  lobules,  which  are  grey  or  pale  pink  and  have  a  firm 
feel,  and  bright  red  portions  of  crepitant  lung.  The  paler  portions  are  pneu- 
monic and  solid  ;  the  red  portions  are  air-containing  congested  lung,  which 
surround  the  pneumonic  portions.  Portions  of  lung  which  are  removed  will 
float  in  water,  but  easily  break  down  on  thrusting  in  the  finger.  The  upper 
lobes  are  emphysematous. 

3.  Acute  Generalised  Broncho-pneumonia,  Pleurisy. — The  posterior 
inferior  or  whole  of  one  or  both  lobes  has  a  semi-solid  feel,  though  less  solid 
than  in  croupous  pneuinonia,  with  but  little  or  no  sense  of  crepitation.  The 
surface  is  purplish  in  colour  ;  the  pleural  covering  may  have  minute  haemor- 
rhages on  its  surface,  or  be  roughened  from  the  pixsence  of  lymph.  The  cut 
section  has  a  solid  feel,  yet  it  is  not  granular  as  in  true  croupous  pneumonia, 
but  easily  breaks  down  on  pressure  with  the  finger,  and  sinks  in  water.  It 
has  a  mottled  appearance,  in  consequence  of  the  lobules  surrounding  the 
terminal  bronchi  being  paler  in  colour  and  in  a  later  stage  of  consolidation 
than  the  intervening  portions  of  lung.  There  will  probably  be  collapse 
of  the  anterior  and  inferior  edges,  as  well  as  acute  emphysema  in  the 
same  positions  ;  some  of  the  vesicles  are  frequently  distended  to  the  size  of 
millet  seeds,  or  even  peas,  and  perhaps  one  here  and  there  is  ruptured.  In 
a  still  later  stage,  especially  if  the  inflammation  is  intense,  as  in  measles  or 
scarlet  fever,  a  lobe  may  be  solid,  and  on  the  surface  beneath  the  pleura 
there  are  a  number  of  yellow  spots,  the  size  of  millet  seeds  or  larger,  which 
on  pricking  yield  a  drop  of  thick  pus.  On  section,  these  yellow  spots  are  seen 
scattered  through  the  lung;  they  are  the  '  graines  jaunes,'  or  '  abcfes  peri- 
bronchique,'  of  French  authors,  and  are,  in  fact,  minute  abscesses  surrounding 
the  terminal  bronchioles,  formed  by  the  softening  of  the  pneumonic  lobules. 
Pleurisy  with  lymph  or  serum  may  be  present  ;  when  the  pneumonia  is  double 
the  temperature  usually  runs  high. 

The  following  case  illustrates  this  form  of  pneumonia  : 

Acute  Double  Pleuro-pneumonia,  Hyperpyrexia,  Suspicion  of  Meningitis. — John  H., 
aged  14  months  ;  admitted  April  26,  1894.  His  mother  states  he  has  been  a  healthy  child 
up  to  the  present  illness.  A  fortnight  ago  he  became  ill  with  cough  and  fever.  Breathing 
has  been  very  bad  at  nights.     He  vomits  frequently.      He  is  fairly  well  nourished  ;  his 


Bi'onc]io-p7ieH  nionia  3  6 1 

head  is  somewhat  retracted,  ami  muscles  of  the  neck  are  rigid.  The  right  apex  in  front 
and  the  base  behind  are  very  dull  ;  bronchial  breathing  and  sharp  crepitation  are  heard  over 
this  area.  On  the  left  side  there  are  rales,  but  no  dulness  ;  Sij  of  clear  serum  were  with- 
drawn from  the  right  side  behind.  Temperature  103°.  Vomits  constantly.  April  27. — 
General  convulsions,  mostly  right-sided  ;  marked  rigidity  of  the  neck  ;  vomits  constantly. 
Well-marked  iache  cdn'hralc.  April  28. — Very  short  breathing  ;  dulness  well  marked  at 
the  left  base  as  well  as  the  right.  Oxygen  given.  Temperature  io6''-'.  Graduated  bath. 
April  29. — Marked  retraction  of  the  neck  ;  constant  vomiting.  Temperature  io6'4°. 
April  29. — Temperature  106-4°  twice  during  the  day.     Death  May  i. 

Post-mortem. — Right  pleural  cavity  contains  5j  of  yellow  serum,  and  lymph  covering 
the  lower  lobe,  which  is  partly  compressed  and  partly  solid  ;  upper  lobe  solid  at  the  back, 
showing  broncho-pneumonia  and  emphysema  in  front ;  low.er  lobe,  lymph  on  surface, 
pneumonia  on  section.  Much  clear  fluid  escaped  from  surface  of  the  brain  and  lateral 
ventricles  ;  no  lymph  anywhere.  Arachnoid  cloudy ;  veins  full.  It  was  suggested  that 
the  infant  had  meningitis  complicating  the  pneumonia,  but  this  was  not  borne  out  by  the 
autopsy. 

4.  In  infants  under  6  months  a  form  of  pneumonia  is  sometimes 
found  which  does  not  agree  with  the  above  description.  A  lobe,  generally 
one  of  the  lower,  is  semi-solid,  its  surface  depressed  and  purple,  surrounded, 
perhaps,  by  raised  emphysematous  vesicles.  The  cut  section  is  smooth  and 
of  a  uniform  plum  colour,  the  lobules  indistinct  and  airless,  but  the  lung  has 
not  the  solid  feel  of  red  hepatisation. 

5.  In  some  cases  nodules  of  fibrinous  pneumonia  as  large  as  hazel  nuts 
or  walnuts,  hard,  and  with  a  granular  surface,  may  be  found.  We  have  seen 
this  condition  in  connection  with  measles. 

It  has  already  been  remarked  that  clinically  broncho-pneumonia  some- 
times so  closely  simulates  croupous  pneumonia  that  it  is  difficult  to  say  to 
which  variety  it  is  to  be  referred.  The  same  difficulty  may  occur  in  the 
f)ost-niorteni  room,  as  some  lobular  pneumonias  have  almost  the  solid  feel 
found  in  croupous  pneumonia,  and  a  microscopic  examination  shows  the 
air  vesicles  to  contain  fibrin,  and  yet  the  section,  to  the  naked  eye,  is  not 
granular  as  it  is  in  red  hepatisation,  but  mottled,  the  clusters  of  lobules 
varying  in  tint,  and  more  closely  resembling"  in  appearance  the  condition  of 
broncho-pneumonia. 

The  micro-organisms  present  in  the  broncho-pneumonia  occurring 
in  childrert  have  been  studied  by  recent  observers,  more  especially  by 
Neumann,'  Queisner,"  Strelitz,'  and  Prudden  and  Northrup.  The  commonest 
micro-organism  found  appears  to  be  the  Frankel-Weichselbaum  diplococcus, 
much  less  often  Friedlander's  bacillus.  In  the  septic  pneumonias  present 
in  scarlet  fever,  measles,  and  diphtheria  various  micrococci — including 
Staphylococcus  pyogeties  aicretts  and  albus^  and  Streptococcus  pyogettes — are 
usually  present.  In  the  present  state  of  our  knowledge  it  is  unwise  to  lay  too 
much  stress  on  the  presence  of  these  organisms  in  the  pneumonic  lungs  ;  but 
it  seems  exceedingly  probable  that  there  are  several  micro-organisms  which, 
if  the  conditions  are  favourable,  are  capable  of  giving  rise  to  inflammation  of 
the  lungs. 

Diagnosis. — A  clinical  distinction  between  the  above  conditions  is  often 
impossible,    inasmuch   as  bronchitis,    collapse,    emphysema,  and   catarrhal 

1  Jahrbucii  Khidcrh.  Band  x.xx.  p.  233.  2  ^„^    ^-//_  Band  xxx.  p.  277 

•^  Arcliiv  f.  Kiiiderh.  Band  xiii.  p. 468. 


362  Diseases  of  the  Respiratory  Apparatus 

pneumonia  may  all  exist  in  the  same  lung,  and  more  or  less  mask  one 
another.  However,  a  few  points  may  be  emphasised.  In  simple  bronchitis 
the  temperature  is  rarely  high,  there  is  no  impairment  of  resonance,  and  the 
moist  sounds,  if  present,  are  indistinct  and  distant.  In  broncho-pneumonia 
the  temperature  is  higher,  usually  there  is  impaired  resonance,  perhaps 
whiffy  or  bronchial  breathing,  and  the  moist  sounds  are  clear,  sharp,  and 
ringing.  The  diagnosis  of  collapse  is  much  more  uncertain  unless  much 
lung  is  involved  ;  then  there  are  impaired  resonance  and  weak  and  distant 
bronchial  sounds. 

In  all  cases  of  broncho-pneumonia  we  must  bear  in  mind  the  possibility 
of  some  localised  collection  of  pus  being  present  over  a  dull  patch,  and  also 
that  the  case  may  be  one  of  miliary  tubercle  as  well  as  broncho-pneumonia. 

Treatment. — The  colds  in  the  head  and  bronchial  catarrhs  of  children 
call  rather  for  careful  hygiene  than  active  treatment.  Confinement  to  a  well- 
warmed  and  ventilated  room  or  suite  of  rooms,  as  long  as  the  symptoms  of 
a  cold  are  present  or  rhonchi  are  heard  in  the  chest,  with  a  light,  mostly  fluid 
diet,  will  in  many  cases  be  all  that  is  necessary.  Merely  to  confine  a  child 
to  the  house  and  let  it  run  about  in  cold  passages  and  stand  in  draughts  is 
useless,  and  likely  to  give  rise  to  another  cold  before  the  first  has  completely 
passed  away.  Some  children  are  exceedingly  liable  to  take  cold,  and  bron- 
chitis follows  very  readily,  and  with  these  extra  care  must  be  taken,  and  the 
last  trace  of  a  cold  must  have  disappeared  before  they  are  permitted  to  go 
out.  In  those  cases  where  there  is  a  laryngeal  or  tracheal  catarrh  the  cough  is 
often  troublesome,  especially  keeping  the  patient  awake  at  night  and  disturb- 
ing the  whole  household.  Among  the  household  remedies  for  coughs  which 
are  useful  are  black  currant  jelly,  glycerine  lozenges,  liquorice,  and  jujubes 
simple  or  medicated.  A  cup  of  hot  beef  tea  or  cocoa  the  last  thing  at  night 
will  often  soothe  a  troublesome  cough.  In  many  cases  it  will  be  necessary 
to  give  small  doses  of  some  sedative,  especially  in  the  case  of  older  children. 
Morphia,  codeia,  aconite,  hyoscyamus,  bromide  of  ammonium,  may  be  given 
for  this  purpose,  made  up  in  the  form  of  a  linctus  with  syrup  of  orange  or 
tolu  or  glycerine.  The  morphia  and  ipecacuanha  lozenges  of  the  B.P.  made 
with  fruit  paste  or  glycerine  jelly  are  very  convenient.  Codeia  jelly  acts 
exceedingly  well  in  soothing  irritable  coughs. 

The  diet  should  consist  largely  of  fluids,,  hiilk,  beef  tea,  light  puddings. 
Lemonade,  barley  water,  linseed  tea,  to  assuage  thirst  and  tend-  to  produce 
free  action  of  the  kidneys  and  skin,  are  likely  to  be  useful  ;  salines  such  as 
citrate  of  ammonia  or  potash,  or  liq.  ammon.  acet.,  may  also  be  given. 

The  prevention  of  attacks  of  bronchial  catarrh  and  colds  is  a  matter  of 
much  importance,  especially  in  the  case  of  those  who  are  liable  to  bronchitis 
or  asthmatic  attacks  whenever  they  take  cold.  A  house  in  a  dry  and  bracing 
situation,  with  well-warmed  living  rooms,  passages,  and  bedrooms — while 
the  ventilation  and  sanitation  are  carefully  looked  after- — ^is  a  first  necessity 
in  the  prevention  of  colds.  Care  must  be  taken  that  such  children  are 
properly  clothed  with  well-fitting  woollen  under-garments,  that  they  have 
plenty  of  exercise  in  the  open  air  whenever  the  weather  is  suitable,  while  cold 
sponging  or  the  tepid  douche  in  the  morning  whilst  standing  in  warm  water  is 
of  much  service  in  promoting  the  circulation  in  the  skin  and  preventing  chills. 

Are  '  colds    in  the  head '  infectious  ?     It  is  a  common  experience  that 


Broncho-pneumonia  363 

almost  a  whole  household  is  affected  at  the  same  time  or  in  succession,  and 
there  can  be  little  doubt  that  in  some  cases  a  nasal  catarrh  passes  from  one 
child  to  another  without  the  latter  having  been  exposed  to  any  chill.  Other 
conditions  favouring  these  attacks  may  be  present,  but  of  these  next  to 
nothing  is  known.  Possibly  a  chill  may  predispose  the  mucous  membrane 
to  take  on  inflammation  or  become  a  suitable  nidus  for  the  cultivation  of 
bacilli  or  other  organisms  present  in  the  atmosphere. 

If  the  catarrh  passes  downwards  from  the  trachea  into  the  smaller  tubes, 
and  the  child  in  consequence  '  wheezes '  and  rhonchi  are  heard  all  over  the 
chest,  the  child  should  be  confined  to  its  bed  or  cot,  care  being  taken  to  have 
it  warmly  clothed  and  in  a  situation  free  from  draughts.  In  the  more  severe 
cases  of  bronchitis  and  catarrhal  pneumonia,  especially  in  small  children,  a 
sort  of  tent  should  be  rigged  over  the  cot,  or  one  or  two  clothes  screens  placed 
around  with  sheets  hung  on  them  so  as  to  form  sides  and  a  roof  will  answer 
very  well.  The  atmosphere  must  be  kept  moist  by  means  of  a  bronchitis 
kettle,  or  the  sheets  which  form  the  walls  of  the  tent  may  be  kept  moist. 
The  temperature  in  the  cot  should  be  maintained  at  65°-7o''  night  and 
day.  The  diet  should  consist  entirely  of  fluids  if  the  attack  is  at  all  acute. 
Milk  diluted  with  one-third  or  one-fourth  part  of  whey,  barley  water,  or  soda 
water  should  form  the  principal  kind  of  nourishment  ;  a  cup  of  beef  tea 
once  or  twice  a  day  may  be  allowed.  Moist,  hot  applications  to  the  chest 
are  soothing  to  the  patient,  and  may  be  applied  in  the  form  of  linseed  poultices 
or  fomentations.  It  must,  however,  be  borne  in  mind  that  poultices  made  by 
unskilled  hands  may,  especially  in  the  case  of  infants  and  young  children, 
do  more  harm  than  good  ;  to  surround  the  chest  of  an  Infant  with  a  heavy 
poultice  when  the  bronchial  tubes  are  choked  with  thick  mucus  and  patches 
of  lung  are  in  a  state  of  collapse  is  simply  to  invite  death  by  suffocation.  The 
poultices  should  be  well  mixed,  being  not  too  heavy  nor  applied  too  hot 
(placing  them  against  one's  cheek  is  the  best  guide),  carefully  kept  in  position 
by  means  of  a  flannel  binder,  and  renewed  at  least  every  four  hours.  A 
mustard  poultice  is  often  of  great  service  in  the  early  stage  ;  one  tablespoonful 
of  mustard  to  four  or  five  tablespoonfuls  of  linseed  meal  may  be  used,  the 
poultice  remaining  on  for  three  or  four  hours.  This  strength  is  not  sufficient  to 
produce  more  than  some  redness,  and  it  can  be  renewed  or  replaced  by  a 
simple  poultice  according  to  circumstances.  For  infants  and  young  children 
hot  fomentations  applied  by  means  of  spongio-pilinejor  flannel  are  preferable 
to  poultices  :  they  are  much  more  cleanly,  and  harm  is  less  likely  to  be  done 
by  their  application.  Several  layers  of  flannel  may  be  used  wrung  out  of 
water,  or  if  need  be  mustard  and  water,  and  covered  with  a  piece  of  oiled 
silk,  the  whole  being  surrounded  by  cotton  wool.  Poultices  and  hot  applica- 
tions are  of  most  service  in  the  early  stages,  when  the  mucous  membrane  is 
swollen  and  dry,  and  the  secretion  scanty  ;  in  the  later  stages  they  are  also 
useful  if  the  secretion  is  thick  and  coughed  up  with  difficulty. 

In  the  early  stage  of  bronchitis,  if  there  is  much  wheezing,  dyspnoea,  and 
■distress,  an  emetic  is  of  much  service,  more  so,  perhaps,  in  bronchitis  han  in 
catarrhal  pneumonia.  Pulv.  ipecac,  in  5 -grain  doses  in  syrup  of  orange 
peel  may  be  given  to  a  child  under  2  years  of  age  and  repeated  in  a  few 
minutes  if  it  fail  to  act.  The  act  of  vomiting,  especially  after  ipecacuanha, 
will  probably  be  attended  by  a  freer  secretion  of  mucus  and  relief  to   the 


364  Diseases  of  the  Respiratory  Apparatus 

breathing.  At  this  period  the  depressant  expectorants  which  appear  ta 
diminish  tension  in  the  vessels,  and  thus  reHeve  the  congested  mucous 
membrane  are  mostly  used.  Of  these  antimony,  ipecac,  and  aconite  are 
more  frequently  used  than  any  others.  In  this  stage,  when  the  cough  is 
hard  and  sibilus  is  heard  in  the  chest,  antimony  in  small  repeated  doses, 
short  of  producing  nausea  and  depression,  is  of  much  service.     (F.  46.) 

In  catarrhal  pneumonia  aconite  in  half-minim  or  mmim  doses  is  preferable. 
The  drug  may  be  continued  for  several  days,  as  long  as  the  fever  lasts  or 
the  secretion  remains  scanty  or  is  coughed  up  with  difficulty.  Given  with 
caution  and  in  small  doses  there  is  little  fear  of  its  producing  too  great  de- 
pression ;  in  feeble  children,  however,  it  may  be  well  to  give  small  doses  of 
alcohol  at  the  same  time.  Many  prefer  to  give  ipecac,  or,  instead  of  aconite, 
antimony,  especially  in  the  feeble  and  cachectic  patients  so  often  met  with 
in  the  out-patient  room.  Some  believe  ipecac,  combined  with  alkalies  such 
as  bicarbonate  of  potash  to  be  of  especial  value  when  mucous  rales  are  heard 
in  the  chest,  and  the  infant  or  child  has  much  difficulty  in  coughing  up 
the  thick  secretion  which  is  formed.  Simple  salines  are  preferred  by  some. 
Dr.  Lewis  Smith  recommends  tr.  veratri  viridis  in  half-minim  or  minim  doses 
every  second  hour.  As  long  as  the  cough  remains  hard,  and  the  mucous  secre- 
tion scanty  or  difficult  to  expel,  the  antimony  or  ipecac,  should  be  persevered 
with,  and  is  far  more  likely  to  be  of  service  than  the  stimulating  mixtures  so 
often  prescribed.  It  is  when  the  catarrh  continues,  the  cough  becoming 
loose,  the  secretion  liquid,  and  the  fever  is  mostly  gone,  that  carbonate  of 
ammonia,  squills,  and  terebene  are  most  likely  to  be  useful.  At  this  stage 
the  fomentations  and  poultices  should  be  given  up  in  favour  of  a  warm 
cotton-wool  jacket,  and  stimulating  applications  maybe  applied  to  the  chest 
walls.  Ammonia  may  be  usefully  combined  with  digitalis  and  squills,  as  in 
F.  60. 

Stimulating  applications  to  be  rubbed  into  the  chest-wall  are  useful  in 
producing  slight  redness  Avithout  being  too  severe.  (F.  61,  F.  62,  F.  63.) 
The  lin.  potass,  iodidi  c.  sapone  B.  P.  may  be  used  in  a  similar  way. 
Iodide  of  potassium  is  often  useful  in  the  subacute  or  chronic  stage,  and 
nitric  acid  and  nux  vomica  are  of  much  service  during  convalescence. 

In  bronchitis  pure  and  simple  the  temperature  is  never  so  excessive  as  to 
require  any  antipyretic  treatment,  but  in  some  cases  of  acute  broncho-pneu- 
monia, especially  where  it  approaches  the  croupous  type,  or  when  it  accom- 
panies whooping  cough  or  measles,  the  temperature  is  apt  to  take  high  flights. 
Sponging  with  tepid  water,  '  packs,'  or  when  there  is  drowsiness  or  con- 
vulsions the  warm  bath  gradually  cooled  down  by  adding  cold  water  so  as 
to  reduce  it  to  60°,  may  be  used.  Phenacetin  or  antipyrin  may  be  used  for 
the  same  purpose  with  care,  beginning  with  a  small  dose,  2  grains  of  the 
former  for  a  child  of  2  or  3  years  of  age.  Both  of  these  antipyretics  have 
been  used  in  small  doses  frequently  repeated,  in  acute  bronchitis  and  in 
broncho-pneumonia.  An  excessively  high  temperature,  io4°-io5°,  is  some- 
times present  in  an  early  stage  of  pneumonia,  accompanied  by  convulsions 
or  coma  ;  in  such  cases  no  time  should  be  lost  in  resorting  to  baths  or  packs, 
while  giving  stimulants  if  necessary  by  the  rectum. 

Death  usually  threatens  in  bronchitis  or  broncho-pneumonia  from 
mechanical  interference  with  the  air  entering  the  lungs,  asphyxia  being  pro- 


Broncho-pneunw7iia  365 

cluced  with  great  depression  of  the  heart's  action.  This  occurs,  especially  in 
young  infants,  by  a  blockage  of  the  medium-sized  and  small  tubes  by  thick 
mucus  which  is  difficult  to  expel,  or  is  due  to  capillary  obstruction,  collapse 
of  lung,  acute  emphysema,  or  a  large  tract  of  lung  becoming  involved  in  the 
pneumonic  process.  In  young  infants  with  obstructed  bronchial  tubes  all 
tight  binding  up  of  the  chest  walls  by  poultices  or  bondages  must  be 
a\oided  ;  the  position  must  be  varied  from  time  to  time  so  as  to  give  each 
lung  full  play  in  turn,  and  an  occasional  emetic  of  alum  or  squills  will  help 
to  get  rid  of  the  excessive  and  tenacious  secretion.  The  nurse's  finger  may 
be  usefully  employed  in  removing  the  secretion  from  the  back  of  the 
throat  after  a  fit  of  coughing.  In  suddenly  produced  dyspnoea  either  from 
collapse  of  lung  or  acute  pneumonia,  when  the  circulation  through  the  lungs 
is  obstructed  and  the  right  heart  over-distended,  local  bleeding  by  means  of 
a  leech  or  two  is  often  of  the  greatest  service,  and  may  be  the  means  of 
saving  life.  One,  two,  or  three  leeches  may  be  applied  at  the  tip  of  the 
sternum,  and  after  they  fall  off  the  bleeding  may  if  necessary  be  encouraged 
by  warm  applications.  Mustard  baths,  or  mustard  fomentations,  or 
turpentine  stupes  applied  to  the  chest  are  likely  to  be  useful  in  those  cases 
where  there  is  extensive  pneumonia  with  much  dyspnoea  and  cardiac 
depression — turpentine  must  be  used  cautiously.  Ammonia,  strychnine,  and 
digitalis  must  also  be  freely  given  under  similar  circumstances.  Oxygen 
inhalation  may  be  resorted  to,  but  the  oxygen  must  be  given  freely  to  be  of 
much  use. 

The  c[uestion  of  the  administration  of  emetics,  alcohol  and  opium  is  of 
importance.  Emetics  are  mostly  of  value  in  the  early  stages  of  laryngitis  or 
bronchitis  when  the  cough  is  hard  and  the  breathing  difficult  on  account  of 
the  swollen  condition  of  the  mucous  membrane  ;  a  freer  secretion  follows  the 
administration,  and,  moreover,  the  unloading  of  the  stomach  of  the  accumu- 
lated mucus  and  undigested  food  seems  to  have  a  good  effect  ;  ipecacuanha 
or  sulphate  of  zinc  answers  best  at  this  stage.  Emetics  are  sometimes 
useful  in  a  later  stage  of  bronchitis  and  collapse  when  the  bronchial  tubes 
are  choked  with  mucus,  provided  there  is  no  pneumonia  or  cyanosis  ;  10  to 
30  grains  of  alum  in  a  teaspoonful  of  syrup  of  squills  is  preferable  to 
ipecac,  or  zinc  at  this  time.  Alum  and  honey  may  be  given  to  infants  on  a 
small  brush.  Alcohol  is  unnecessary  in  the  early  stages,  and  it  should 
always  be  used  with  caution  in  the  later  stages,  for,  like  opium,  it  soothes 
the  cough,  and  in  large  quantities  its  effect  is  narcotic  ;  it  is  therefore 
contra-indicated  except  in  small  doses  if  there  is  any  tendency  to  cyanosis. 
Opium  in  the  form  of  Dover's  powder  is  often  of  great  value  if  the  child  is 
restless  and  its  cough  irritable,  but  it  is  perhaps  needless  to  say  it  should 
on  no  account  be  given  if  there  is  much  dyspnoea  due  to  the  accumulation  of 
mucus  in  the  bronchial  tubes  or  if  much  lung  is  involved. 

During  an  acute  attack  of  bronchitis  or  pneumonia  the  digestive  organs 
are  very  apt  to  suffer  ;  there  may  be  vomiting,  flatulence,  and  diarrhoea. 
This  impaired  digestion  must  always  be  borne  in  mind  when  the  question 
of  dieting  is  being  discussed,  and  care  must  be  taken  not  to  overload 
the  stomach  and  bowels  with  too  large  a  quantity  of  milk,  beef  tea,  &c. 
An  occasional  laxative  dose  of  calomel  or  rhubarb  and  soda  may  be 
useful. 


566 


Diseases  of  the  Respiratory  Apparatus 


It  is  well  to  bear  in  mind  the  possibility  that  an  infant  may  recover  from 
an  acute  attack  of  bronchitis,  to  finally  succumb  to  agastro-intestinal  atrophy 
datin"'  from  the  acute  bronchial  attack. 


Croupous    Pneumonia 

Croupous  pneumonia  in  its  typical  form  is  a  common  disease  in  children 
over  three  years  of  age,  and  does  not  differ  either  in  its  course  or  morbid 
anatomy  from  the  attacks  in  young  adults,  though  the  mortality  is  much 
less.  Reference  has  already  been  made  to  the  acute  lobar  pneumonias  of 
infancy  and  childhood,  which  are  frequently  classed  amongst  the  fibrinous  or 
genuine  croupous  pneumonias  on  account  of  the  extent  of  lung  involved  and 
also  of  their  termination  by  crisis.  That  many  of  them  are  fibrinous  to  some 
extent  is  certain,  as  effused  fibrin  may  be  seen  in  sections  prepared  for  the 
microscope,  but  in  our  experience  such  lungs  when  seen  on  Xk\&  post-mortem 
table  are  more  spongy  and  lack  the  complete  solidity  of  the  red  hepatisation 
of  true  croupous  pneumonia,  and  the  outlines  of  the  lobules  are  readily  seen 
in  consequence  of  their  differing  from  one  another  as  to  the  extent  to  which 
they  are  affected.  Moreover,  while  they  may  contain  fibrin,  the  cellular 
element  largely  predominates.  Fortunately  it  is  of  little  practical  moment 
under  which  division  these  pneumonias  are  classed  :  hybrid  cases  are  certain 
to  come  under  observation  both  in  infancy  and  childhood,  and  we  have 
frequently  to  be  content  with  describing  attacks  as  being  of  the  '  croupous 
type,'  or  of  the  'catarrhal'  or  'broncho-pneumonic'  type,  according  as  their 
symptoms  resemble  typical  attacks  of  either  the  one  or  the  other.  It  is  the 
difficulty  of  classifying  hybrid  cases  that  makes  the  statistics  of  one  hospital 
or  one  year  liable  to  error  when  compared  with  that  of  other  hospitals  or 
years. 

The  statistics  (given  below)  of  our  own  hospital  of  the  cases  entered  as 
croupous  pneumonia  during  the  years  1878- 1893  illustrate  the  comparative 
frequency  of  the  disease  at  different  ages.  In  this  series  of  cases  the  total 
mortality  amounted  to  5-2  per  cent,  the  highest  being  among  children  under 
two  years  of  age.  ^ 

Table  showing  the  Ages  and  Mo7'tality  of  708  Cases  of 
Croupous  Pneumonia 


Under  2  years 

2  to  5  years 

5  to  10  years 

10  to  14  years 

Total 

Deaths 

Total    Deaths 

Total  j  Deaths 

Total 

Deaths 

Total 

Death 

29          8 

213            21 

338 

8 

128 

I 

708 

38 

The  etiology  of  croupous  pneumonia  is  not  perhaps  quite  as  simple  as  it 
seems  at  first  sight.  A  schoolboy  is  exposed  to  a  cold  east  wind  after 
getting  hot,  or  is  chilled  by  a  fall  into  water,  and  a  few  days  later  develops 
an  acute  pneumonia  :  in  such  cases  there  can  be  little  doubt  that  pneumonia 

1  These  figures  closely  correspond  with  those  given  by  Von  Dusch  ;  in  331  of  his  cases 
of  croupous  pneumonia  in  children  under  10  years  of  age  the  mortality  was  4-8  per  cent. 


Croupous  Pneumonia  367 

in  some  way  or  other  is  the  result  of  a  chill.  In  connection,  however,  with 
this,  our  own  hospital  statistics  do  not  show  much  clifiference  in  the  number 
of  cases  admitted  during  the  different  months  of  the  year,  though  there  is  a 
slight  preponderance  in  favour  of  March.'  Attacks  certainly  occur  at  all 
times  of  year,  in  the  warmer  as  well  as  in  the  colder  months.  On  the  other 
hand,  it  is  quite  certain  that  croupous  pneumonia  is  at  times  epidemic  and 
also  infectious,  affecting  several  members  of  the  same  household  or  the  same 
street,  and  in  a  few  instances  there  have  been  widespread  epidemics,  as,  for 
instance,  during  the  influenza  epidemic  of  1891.  Epidemics  of  pneumonia 
associated  with  tonsillitis  have  occurred  in  schools  and  other  large  institutions 
where  the  sanitary  arrangements  have  been  found  faulty.  It  may  be  taken 
for  certain  that  while  there  is  a  form  of  pneumonia  of  the  croupous  type 
which  follows  a  chill,  it  may  be  produced  by  other  causes,  such  as  infection  by 
the  inhalation  of  the  Frankel-Weichselbaum  diplococcus  or  the  influenza 
bacillus,  or  it  may  be  part  of  some  general  septic  poisoning.  In  some 
instances  acute  pneumonia  has  followed  injury  ;  a  blow  on  the  chest  or  a 
fall  on  the  head  has  been  followed  a  few  days  later  by  a  pneumonic  attack. 

It  seems  to  us  that  it  is  more  than  probable  that  these  micro-organisms 
are  incapable  of  setting  up  pneumonia  in  healthy  lung  in  a  normal  condition  ; 
but  if  the  individual  has  caught  cold  or  is  in  a  low  state  of  health  a  suitable 
soil  is  produced,  and  if  an  infection  takes  place  a  pneumonia  is  the  result. 

The  pneumonic  diplococcus  appears  to  be  almost  constantly  present  in 
the  sputa  of  cases  of  croupous  pneumonia  in  the  early  stage,  but  it  is  also 
found  in  the  pus  from  an  acute  otitis  and  also  in  the  effusion  in  cerebro- 
spinal meningitis.  It  has  been  found  in  the  sputa  of  healthy  children.  It 
can  hardly  be  said  to  be  pathogenic  of  pneumonia,  but  it  is  apparently 
capable  of  setting  up  pneumonia  under  certain  conditions. 

In  different  epidemics,  or  in  different  years  or  localities,  attacks  of 
pneumonia  appear  to  vary  in  their  character,  sometimes  being  of  the 
sthenic,  sometimes  of  asthenic  type  :  this  has  been  specially  described  by 
Foxwell.-' 

Syniptoms  and  Course. — The  onset  is  sudden,  with  symptoms  not  unlike 
those  of  scarlet  fever  ;  there  are  high  fever,  dyspnoea,  rapid  pulse,  headache, 
pain  in  the*  side  or  abdomen,  short  cough,  and  perhaps  vomiting  and 
diarrhcea.  In  children  under  three  years  convulsions  are  not  uncommon  at 
the  onset,  but  these  are  rare  in  older  children  :  the  convulsions  may  prove 
fatal  before  the  attack  of  pneumonia  has  fully  declared  itself  Delirium  may 
be  an  early  symptom,  especially  if  the  fever  is  high.  By  the  time  a  medical 
examination  is  made  the  child  is  usually  too  ill  to  be  about,  and  is  either  in 
bed  or  being  nursed  in  its  mother's  arms  ;  the  cheeks  are  flushed,  the  alas 
nasi  are  working,  the  respirations  are  perhaps  doubled,  being  possibly  40 
per  minute  or  more,  the  pulse  120  to  140,  there  is  a  temperature  of  104°  or 
thereabouts,  the  tongue  is  dry  and  brown,  and  there  may  be  herpetic  vesicles 
on  the  lips  and  nose.  An  examination  of  the  urine  shows  it  to  be  dark  in 
colour,  concentrated,  containing  albumen  and  an  excess  of  urea,  and  deficient 
in  chlorides.     The  cough  is  dry  and  hacking,  and  pain  is  often  complained  of 

^  In  628  cases  of  croupous  pneumonia  during  the  j'ears  1857-1885  Durasz  found  a 
slight  excess  in  April  and  May. 
-  Practitioner,  July  1886. 


368  Diseases  of  the  Respiratory  Apparatus 

during  the  act ;  in  young  children  there  is  no  expectoration,  in  older  ones 
there  may  be  the  usual  rusty  sputa.  The  fever  and  dyspnoea  continue,  the 
child  remaining  very  ill  till  the  end  of  the  week,  when,  usually  between  the 
sixth  and  the  ninth  day,  the  fever  suddenly  abates,  and  a  marked  improvement 
takes  place  in  all  the  symptoms,  so  that  it  is  evident  to  all  that  the  crisis  has 
come.  The  crisis  is  sometimes  marked  by  collapse,  the  child  becoming  cold 
and  clammy,  with  a  subnormal  temperature. 

Physical  Signs. — An  examination  of  the  chest  on  the  first  or  second  day 
of  the  attack  will  usually  lead  to  the  discovery  of  more  or  less  consolidated 
lung.  Careful  percussion,  striking  now  lightly,  now  more  forcibly,  will  elicit 
a  certain  high-pitched  note  of  impaired  resonance  over  some  part  of  the 
chest  wall,  as  in  the  infra-clavicular,  axillary,  or  scapular  region,  or  over  the 
root  or  base  of  the  lungs  ;  on  listening  over  the  affected  area  some  departure 
from  the  normal  breath  sounds  will  probably  be  heard.  They  may  be 
simply  weak  or  distant  breathing,  as  if  the  air  is  not  entering  freely  into 
some  part  of  the  lung  ;  there  may  be  distant  or  intense  bronchial  breathing, 
of  various  abnormal  sounds,  as  a  pleuritic  rub,  rhonchus,  or,  more  often, 
subci-epitant  or  loose  ringing  rales,  the  fine  crepitation  so  common  in  adults 
being  generally  absent.  There  are  usually  increased  vocal  resonance  and 
fremitus,  though  it  is  not  always  possible  to  elicit  these  signs  unless  the  child 
cries.  If  there  is  much  lung  affected,  loud  or  harsh  breath  sounds  are  heard 
over  the  non-aifected  lung,  and  care  must  be  taken  not  to  mistake  these  signs 
of  an  overworked,  for  those  of  an  affected  lung. 

The  position  of  the  consolidation  varies  considerably  and  does  not 
necessarily  correspond  to  a  lobe,  but  may  occupy  the  whole  extent  of  lung 
anteriorly  or  posteriorly  ;  or  the  most  marked  signs  man  be  first  detected  over 
the  root  of  the  lung  behind  or  in  the  axilla.  The  left  base  and  right  apex  are 
favourite  spots  to  be  attacked,  but  any  part  of  the  lung  may  be  invoh'ed, 
though  it  must  be  borne  in  mind  that  the  apices  are  more  apt  to  be  affected 
in  children  than  in  adults,  and  it  is  just  at  this  spot  that  early  signs  are  apt  to 
be  overlooked.  In  the  course  of  a  day  or  two,  sometimes  not  for  several,  the 
physical  signs  become  more  marked,  the  dulness  cannot  be  mistaken,  the 
bronchial  breathing  becomes  whiffy  and  intense  ;  in  a  few  days  more,  usually 
after  the  crisis  has  arrived,  coarse,  loose,  crepitant  rales  are  heard  which 
mark  the  resolution  of  the  pneumonic  lung.  The  dulness  and  bronchial 
bi-eath  sounds  and  rales  disappear,  but  some  want  of  resonance  is  apt  to 
remain  for  many  weeks,  as  the  lung  remains  in  an  oedematous  state.  While 
such  is  the  usual  cause  of  events  in  an  ordinary  case,  there  are  marked 
differences  with  regard  to  the  time  when  the  physical  signs  make  their  appear- 
ance, there  being  frequently  a  delay  of  several  days  ;  they  may  even  appear 
as  late  as  the  fifth  day.  It  is  important  to  remember  this,  for  a  mistake  in 
diagnosis  is  easy,  as  a  most  careful  examination  of  the  whole  chest  may  reveal 
nothing  suggestive  of  pneumonia.  In  such  cases  there  is  a  strong  j^iresump- 
tion  that  the  pneumonia  is  centrally  situated,  perhaps  at  the  root  of  the 
lung,  and  takes  some  time  to  approach  the  surface ;  or  possibly  there  may 
be  an  acute  inflammatory  congestion  of  a  portion  of  lung  and  a  delay  in  the 
transudation  of  fibrin  into  the  air-sacs.  Often  a  sub-tympanitic  or  actually  a 
tympanitic  note  to  percussion  and  weak  bronchial  breathing,  or  simply 
distant  respiratory  sounds,  may  be  all  there  is  to  be  heard  for  a  day  or  two. 


Croupous  Pneuinonia 


369 


ft  is  not  easy  to  say  why  a  tympanitic  or  'boxy'  note  is  elicited  over  lung- 
in  a  state  of  acute  inflammatory  congestion,  or  in  the  first  stage  of  an  acute 
lobar  pneumonia,  but  that  it  does  occur  we  have  often  had  the  opportunity 
of  observing.  In  a  few  cases  the  crisis  may  come  and  the  child  recover 
without  the  classical  signs  of  pneumonia  ever  being  present. 

Temperature. — The  temperatui-e  usually  goes  up  suddenly  at  the  onset 
to  104°  or  thereabouts,  and  during  the  course  of  the  attack  continues  high, 
with  slight  morning  remissions,  till  the  crisis,  when  the  fall  is  sudden  (see 
fig.  70),  perhaps  4°  or  5°,  to  a  subnormal  temperature  ;  the  latter  may  last  for  a 
few  days,  and  then  the  normal  line  be  regained.  The  day  on  which  the  crisis 
takes  place  varies  greatly  ;  the  attack  may  end  about  the  fourth  or  fifth  day 


Fig.  70. — Temperature  Chart  of  a  case  of  Croupous  Pneumonia  of  left  apex  in  a  girl  of  five  years. 
Crisis  sixth  day.     Recovery. 

or  earlier,  but  usually  the  crisis  is  delayed  till  the  seventh  or  eighth,  and  in 
the  creeping  form  till  the  end  of  the  second  week  or  later ;  a  post-crisial 
rise  often  occurs  (see  fig.  71),  the  temperature  rising  a  few  degrees  the  fol- 
lowing evening,  becoming  normal  the  next  morning  ;  or  a  relapse  in  which 
the  temperature  remains  elevated  may  take  place  in  consequence  of  another 
portion  of  lung  being  affected.  Post-crisial  hectic,  prolonged  for  some  days 
or  weeks,  suggests  the  presence  of  an  empyema  or  other  compHcation.  In 
the  minority  of  cases  the  temperature  falls  by  lysis. 

Varieiies.— The  course  of  the  attack  varies  ;  these  varieties  have  been 
emphasised  by  various  writers,  especially  by  A.  Baginsky  ;  they  may  be 
enumerated    as    follows:   (i)  Abortive  Pneumonia.      This  variety,  as  the 

B  B 


370  Diseases  of  the  Resph^atory  Apparatus 

name  applies,  aborts,  or  the  course  comes  to  a  sudden  termination  by  crisis, 
after  lasting  two,  three,  or  four  days,  mostly  without  the  classical  signs  of 
pneumonia  being  developed  ;  yet  a  careful  examination  of  the  lungs  will 
discover  some  spot  where  the  breath  sounds  are  weak  and  the  percussion 
note  slightly  raised  or  tympanitic.  Herpes  is  common  on  the  lips  and 
nose.  (2)  Creeping:  or  wandering-  Pneumonia  has  been  compared  by 
Henoch  to  an  attack  of  erysipelas  spreading  over  the  surface  of  the  lung. 
The  apex  is  perhaps  the  first  part  affected  ;  gradually  the  inflammatory 
process  spreads  to  the  base,  and  possibly  finally  attacks  the  opposite  side. 
Such  cases  are  apt  to  have  a  chronic  course,  the  crisis  being  delayed  till  the 
tenth  or  fourteenth  day,  or  the  temperature  may  fall  by  lysis,  or  a  hectic  may 
succeed  in  consequence  of  an  empyema  being  present.  (3)  Relapsing 
Pneumonia  much  resembles  the  creeping  form.  Several  relapses  occur 
after  the  crisis  has  come,  some  patch  of  pneumonia  occurring  in  another 
part  of  the  lung.  We  have  known  cases  in  which  six  or  seven  relapses  have 
occurred.  In  such  cases  we  may  suspect  pus.  (4)  Cerebral  pneumonia. — 
In  this  form  cerebral  symptoms  are  prominent,  while,  in  the  early  stages  at 
least,  the  symptoms  of  pneumonia  are  latent  ;  there  may  be  convulsions, 
delirium,  headache,  and  drowsiness.  In  such  cases  the  fever  usually  runs 
high,  and  the  cerebral  symptoms  maj^  be  due  to  the  high  fever  and  poisoned 
blood.  Not  unfrequently  the  lesion  in  these  cases  is  at  the  apex.  Cough  is 
often  absent.  (5)  Gastric  Pneumonia. — In  these  cases  gastric  symptoms 
are  most  marked  ;  the  attack  may  begin  with  vomiting,  diarrhoea,  coated 
tongue,  fever,  and  abdominal  pain,  and  it  is  only  after  a  day  or  two,  when 
the  classical  signs  appear,  that  a  diagnosis  of  pneumonia  is  made.  The 
attack  may  simulate  gastro-intestinal  catarrh  or  peritonitis,  the  abdo- 
minal pain  being  due  to  diaphragmatic  or  costal  pleurisy.  (6)  Pleuro- 
pneumonia.— In  these  cases  the  signs  of  pleurisy  predominate  ;  there  is 
sharp  stabbing  pain,  tenderness  on  percussion,  and  the  child  screams  when 
it  coughs  or  turns  over  in  bed.  Signs  of  consolidation  are  succeeded  by 
those  of  pleuritic  effiision,  or  an  empyema  possibly  results. 

Complications  and  Sequela;. — Pleurisy  frequently  accompanies  croupous 
pneumonia  ;  percussion  over  the  dull  area  and  deep  pressure  give  pain,  and 
friction  sounds  are  frequently  heard  ;  the  pleurisy  is  apt  to  become  suppura- 
tive in  weakly  children,  especially  if  the  pneumonia  occurs  in  the  course  of 
scarlet  fever,  measles,  or  whooping  cough  (see  infra).  Pericarditis  some- 
times occurs.  Hyperpyrexia,  a  temperature  of  105°  or  106°  occasionally 
taking  place,  accompanied  by  cerebral  symptoms,  convulsions  in  young 
children,  or  stupor  and  delirium  in  older  ones.  IMCening-itis  is  rare,  though  it 
occurs  occasionally  simultaneously  with  the  pneumonia  or  follows  as  a  sequela, 
being  most  common  in  young  children.  Tfephritis  also  occurs  in  associa- 
tion with  pneumonia  ;  usually  the  latter  is  secondary  to  the  former.  Jaundice 
sometimes  accompanies  pneumonia,  especially  of  the  right  base  (see  p.  2)T3)' 
Gang-rene  of  the  lung-  occasionally  supervenes  and  brings  about  a  fatal  , 
result  ;  this  seems  mostly  to  occur  either  in  pneumonia  secondary  to  neph- 
ritis, or  when  pneumonia  occurs  in  a  subject  who  has  emphysematous  lungs. 
The  possibility  of  the  lung  being  adherent  to  the  chest  and  undergoing  an 
indurating  or  fibroid  process  must  be  kept  in  mind.  A  chronic  condition  of 
caseation  may  remain,  but  this  is  much  commoner  after  catarrhal  than  after 


Croupous  Pneumonia 


371 


croupous  pneumonia.  Dlphtberia  of  the  fauces  may  complicate  it  ;  once 
or  twice  we  have  discovered,  to  our  surprise,  late  in  the  attack  or  on  the 
post-)nortcvi  table,  false  membrane  on  the  fauces. 

Prognosis. — The  prognosis  is  favourable  in  cases  of  croupous  pneumonia 
when  it  is  primary  and  attacks  healthy  children  over  three  years  of  age  ; 
among-  such  the  mortality  is  small.  Double  pneumonia  is  necessarily  more 
fatal  than  single,  but  here  the  amount  of  lung  involved  at  one  time  is  not 
necessarily  great,  as  usually  while  it  is  advancing  on  one  side  it  is  receding 
on  the  other  ;  the  danger  depends  on  the  amount  of  lung  involved,  and  the 
respirations  give  a  more  or  less  useful  indication  of  this.  In  a  child  who 
already  suffers  from  chronic  bronchitis  and  emphysema  or  cardiac  disease, 


I— ^Mi1^1^iB—l^^^^^iM—i»J8w^— ^^—M ^^IM^Il^M^^I^M^^^MI^Wa^l^M 


Wv 


■^■^■r^EaH^H^H^HI^gg^HJ^HIH^B  ^Mlga^Hglg  ■■Kp^gB  Wil^CiraHI^EH  KX 


^wisv^nx^tKinnimmiWicVf 


Fig.  71. — Temperature  Chart  of  a  case  of  Croupous  Pneumonia  of  left  lung  in  a  girl  of  five  years  , 
treated  by  cold  baths.     Crisis  fourth  day  ;  post-crisial  rise.     Recovery. 

the  prognosis  is  much  worse.  Secondary  pneumonia,  when  it  follows  or 
complicates  scarlet  fever,  measles,  whooping  cough,  nephritis,  or  follows 
operations  oris  connected  with  septicaemia,  is  necessarily  serious  and  often 
fatal  disease.  When  much  pleurisy  accompanies  the  pneumonia,  especially 
in  young  children,  the  prognosis  is  less  favourable  than  in  cases  of  simple 
croupous  pneumonia. 

Diagnosis.— \vy  those  cases  of  croupous  pneumonia  which  begin  with 
vomiting  and  high  fever,  and  where  the  physical  signs  are  delayed,  there  is 
a  certain  superficial  resemblance  to  scarlet  fever.  That  such  cases  are  liable 
to  be  mistaken  for  scarlet  fever  is  shown  by  the  fact  that  not  uncommonly 
cases  of  acute  pneumonia  are  sent  into  fever  hospitals  certified  as  suffering 


372  Diseases  of  the  Respiratory  Apparatus 

from  scarlet  fever.  A  careful  examination  of  the  patient,  and,  if  necessary,  a 
delay  of  twenty-four  hours  before  coming  to  a  decision,  will,  in  the  large 
majority  of  cases,  prevent  such  an  error.  In  the  first  twenty-four  hours  in  a 
sharp  attack  of  scarlet  fever  there  may  be  high  temperature,  vomiting,  diar- 
rhoea, rapid  pulse  (often  150),  tonsillitis  more  or  less  developed,  no  pain  in 
the  chest,  or  cough.  The  rash  usually  appears  at  the  end  of  twenty-four  hours. 
In  acute  pneumonia  there  may  be  high  fever,  headache,  pain  in  the  chest  or 
abdomen,  dyspnoea,  pulse  perhaps  of  120,  perhaps  some  physical  signs  in 
the  chest,  not  often  vomiting,  diarrhoea,  or  tonsillitis.  There  is  no  rash. 
Acute  pneumonia  with  marked  cerebral  symptoms,  such  as  delirium,  stupor, 
or  headache,  sordes  on  the  teeth,  and  high  fever  may  be  taken  for  typhus. 
A  careful  examination  of  the  lungs  would  generally  decide  ;  in  typhus  there 
may  be  evidence  of  bronchitis  ;  in  pneumonia  there  would  usually  be  some 
want  of  resonance  at  an  apex  or  base,  with  some  distant  or  bronchial  breath- 
ing. The  presence  of  a  characteristic  rash  on  the  third  or  fourth  day  would 
decide  the  diagnosis  ;  it  is  well  to  remember  that  in  children  typhus  is  usually 
a  mild  disease.  In  young  children  an  acute  attack  of  croupous  pneumonia, 
with  high  fever,  convulsions,  drowsiness,  or  coma,  may  be  mistaken  for  acute 
meningitis,  or,  as  a  matter  of  fact,  pneumonia  and  meningitis  may  co-exist. 
We  should,  however,  hesitate  in  the  presence  of  pneumonia  and  a  temperature 
of  104°  or  [05°  to  diagnose  meningitis,  the  cerebral  symptoms  being  due  to 
the  high  temperature  and  poisoned  blood.  In  all  cases  where  a  young  child 
is  suddenly  taken  with  convulsions  and  high  fever,  pneumonia  should  be  sus- 
pected and  a  careful  examination  of  the  lungs  made.  We  must  remember 
that  the  temperature  may  be  high,  104°  or  105°,  as  the  result  of  only  a  small 
patch  of  pneumonia.  In  such  cases,  especially  in  infants,  the  pneumonia  may 
be  overlooked  and  the  temperature  be  attributed  to  teething.  The  diagnosis 
between  croupous  pneumonia  and  generalised  broncho-pneumonia  may  not 
be  easy  during  life ;  we  cannot  often  do  more  than  say  such  and  such  an 
attack  approaches  more  nearly  to  the  croupous  type,  when  there  is  a  sudden 
onset,  a  local  portion  of  lunginvolved,  a  continuous  temperature,  and  a  crisis  ; 
that  it  is  more  of  the  catarrhal  type  when  there  is  much  bronchitis,  an  inter- 
.mittent  temperature,  and  gradual  subsidence  of  the  fever.  The  difficulty  does 
not  always  end  in  "(ti^  post-mortem  room,  as  typical  fibrinous  pneumonia  in 
patches  or  more  widely  distributed  may  be  found  in  one  lung  and  undoubted 
lobular  pneumonia  in  the  other,  while  both  varieties  may  be  present  in  the 
same  lung. 

Pathology. — -In  croupous  pneumonia  the  first  stage  is  that  of  an  inflam- 
matory engorgement  of  an  extended  portion  of  lung,  the  vessels  are  full,  the 
capillaries  are  tortuous  and  distended,  encroaching  on  the  air  space  in  the 
sacs  ;  in  the  second  stage  the  engorged  vessels  relieve  themselves  by  pouring 
out  liquor  sanguinis  and  some  corpuscular  elements  into  the  air  sacs,  which 
become  blocked  with  fibrine,  and  a  condition  of  red  hepatisation  results. 
This  red  hepatisation,  when  seen  at  the  posi-mortejn,  differs  from  the  lobar 
variety  of  catarrhal  pneumonia  in  that  it  is  more  solid  to  the  touch,  and 
presents  a  uniformly  coloured  surface  on  which  the  outlines  of  the  lobules 
cannot  be  distinguished  ;  in  children  it  is  less  often  granular  than  it  is  in 
adults.  In  a  later  stage  grey  hepatisation  is  found,  the  lighter  colour  being 
due  to  the  presence  of  a  greater  number  of  corpuscular  elements.     In  lung 


Croupous  Pneuuioma  373 

in  a  state  of  red  hepatisation,  Fninkel-Weichselbaum  diplococci  may  be 
usually  detected  by  Gram's  method.  In  one  of  our  recent  cases  of  fatal 
croupous  pneumonia,  in  a  boy  of  four  years  of  age,  who  died  on  the  eighth 
day  (having  been  deeply  jaundiced  for  three  or  four  days),  the  left  lung  was 
in  a  condition  of  red  and  grey  hepatisation,  except  at  the  extreme  apex. 
There  were  some  localised  hepatised  patches  in  the  right  base.  We  were 
able  to  obtain  cultivations  on  glycerine  agar  of  the  Frankel-W.  diplococcus, 
Staphylo-coccus  pyog.  aureus^  and  Strepto-coc.  pyogenes. 

T7-eatment. — An  uncomplicated  case  of  croupous  pneumonia  in  a  child  does 
not  require  active  treatment,  as  the  course  is  short,  and  the  heart  and  arterial 
system,  unlike  the  condition  often  found  in  adults,  are  free  from  degenera- 
tions, and  able  to  stand  the  strain  imposed  upon  them.  The  child  should,  of 
course,  be  confined  to  his  bed  in  a  well  warmed  and  ventilated  room  ;  he 
should  be  allowed  only  fluid  nourishment,  such  as  milk,  barley  water,  and 
soda  water.  A  piece  of  spongio-pihne  or  flannel  doubled  several  times 
may  be  wrung  out  of  hot  water,  and  applied  to  the  chest.  Poultices  may  be 
used,  and  retain  the  heat  better  than  anything  else  ;  but  they  are  very 
liable  to  slip  out  of  place,  and  are  unsuited  for  infants  on  account  of  their 
weight.  In  the  early  stages  aconite  is  of  service,  one  or  two  drops  of  the 
tincture  being  given  every  two  or  four  hours,  being  watched  carefully  lest  it 
produce  too  much  depression.  In  many  cases  no  other  treatment  is  required, 
the  aconite  being  stopped  when  the  crisis  comes.  If  the  temperature  is  not 
excessive,  not  much  exceeding  103°,  no  special  methods  of  reducing  it  need 
be  used,  as  the  course  of  the  fever  is  short,  and  often  after  the  first  day  or 
two  it  takes  a  lower  range  ;  the  initial  fever  in  the  case  of  infants  and  young 
children  is  in  some  cases  high,  and  is,  apparently,  the  cause  of  the  cerebral 
symptoms,  such  as  convulsions  and  coma,  from  which  they  suffer,  and 
which  sometimes  prove  fatal.  When  this  is  the  case,  no  time  should 
be  lost  in  reducing  temperature  by  cold  sponging,  packs,  baths,  an  ice 
bag  to  the  chest  over  the  seat  of  the  pneumonia,  or  by  the  administration 
of  antipyretics.  If  the  temperature  is  high — 104°  or  105° — there  is  no 
need  to  fear  any  harm  accruing  from  cold  water,  the  simplest  method  of 
applying  it  being  by  sponging  the  patient,  or — what  is  more  effectual — by  a 
pack  at  6q°  or  70°  ;  this  latter  can  be  applied  by  wringing  a  towel  out  of 
cold  water,  folding  and  applying  it  round  the  chest,  or  enveloping  the  whole 
body  in  a  wetted  sheet.  The  process  may  be  repeated  at  intervals  of  an  hour 
more  or  less.  If  these  means  prove  inefficient,  or  if,  as  in  the  case  of  con- 
vulsions, there  is  no  time  to  lose,  the  cold  or  graduated  bath  should  be 
resorted  to,  the  child  being  placed  in  a  warm  or  lukewarm  bath,  and  the 
temperature  of  the  water  gradually  lowered  to  60°  F.  by  addition  of  cold 
water  or  ice  ;  if  the  patient  becomes  blue  and  cold  he  should  be  removed  at 
once. 

The  best  antipyretics  are  quinine  and  phenacetin,  either  being  given  in 
two  or  three  grain  doses  to  a  child  of  three  years  every  four  hours  ; 
phenacetin  is  apt  to  produce  considerable  depression,  which,  however, 
quickly  passes  away  ;  large  doses  of  quinine  are  apt  to  produce  dyspepsia. 
The  effects  of  aconite  on  the  pulse  should  be  carefully  watched  ;  any  signs 
of  intermission  or  irregularity  should  be  the  signal  for  omitting  it,  for  a  while 
at   least,  and  giving  some   simple  saline,  as  liq.  ammon.   acet.    or  citratis  ; 


374  Diseases  of  the  Respiratory  Apparatus 

alcohol  and  stimulant  expectorants  are  best  avoided  in  the  early  stages  :  two 
or  three  drop  doses  of  tr.  digitalis,  given  every  four  hours,  are  often  useful 
if  the  pulse  is  poor  ;  citrate  of  caffeine  or  sulphuric  ether  may  also  be 
given. 

In  cases  where  the  crisis  is  delayed  on  account  of  the  inflammatory  process 
extending,  as  in  the  creeping  form,  and  when  the  child  seems  low  and  weak, 
there  is  always  a  temptation  to  give  ammonia  and  stimulants,  and  these  may 
in  some  cases  be  needed,  especially  in  hospital  patients  who  are  seen  for 
the  first  time  after  some  days'  illness  ;  but  our  impression  is  that  patients  do 
better  in  the  inflammatory  stages,  when  the  process  is  still  extending,  on 
small  doses  of  aconite,  antimony,  or  salines,  than  they  do  on  a  too  stimu- 
lating treatment.  An  occasional  dose  of  alcohol  may  do  good  when  a  con- 
tinuous dosing  is  harmful  ;  alcohol  in  large  doses  acts  as  a  narcotic,  and  is 
apt  to  add  to  the  drowsiness  and  tendency  to  delirium.  Opium  in  the  form 
of 'nepenthe'  or  Dover's  powder  is  of  great  value  in  calming  the  delirium 
and  sleeplessness,  as  well  as  soothing  the  irritable  cough  and  relieving  pain 
when  this  is  a  marked  feature,  as  it  is  in  the  pleuritic  complications.  One 
to  three  drops  of  nepenthe  or  half  to  two  grains  of  Dover's  powder  may  be 
given  at  night  to  procure  rest  and  sleep.  In  double  pneumonia,  where  there 
is  much  depression  with  a  failing  pulse,  ether  aiid  digitalis  must  be  resorted 
to.  Ether  ma)^  be  injected  in  three  or  five  drop  doses  subcutaneously,  or  sp. 
setheris  and  tr.  digitalis  may  be  given  every  few  hours,  or  inject  strychnine 
subcutaneously  in  doses  of  j;J^-gi^  of  a  grain,  every  hour.  Champagne  is  a 
good  restorative  under  these  circumstances,  but  it  may  cause  vomiting  if 
given  too  freely,  and  it  will  be  well  to  dilute  it  with  soda  water  in  the  case  of 
young  children. 

■Gang^rene  of  the  Kungr 

Croupous  pneumonia,  when  it  attacks  children  already  the  subjects  of 
chronic  bronchitis  and  emphysema,  is  apt  to  terminate  in  gangrene  of  the 
lung  ;  this  we  have  seen  on  several  occasions.  It  is  apt  to  follow  pneumonia 
secondary  to  scarlatinal  nephritis  and  also  whooping  cough.  The  principal 
diagnostic  symptom  is  the  exceedingly  foul  breath  ;  the  temperature  is 
usually  high,  sometimes  hectic,  suggesting  pus,  and  the  pulse  is  rapid.  The 
lung  is  found  at  the  post-inort em  in  a  state  of  grey  hepatisation,  breaking 
down  into  ragged  cavities  and  smelling  offensively. 

Ga7igreiie  of  Lung;  Pyopneumoihorax. — Joseph  P.,  aged  9  )'ears.  Mother  states- 
he  has  been  subject  to  bronchitis  in  the  winter.  On  September  10  he  came  from  school 
complaining  of  a  pain  in  his  side  and  bad  cough.  He  has  been  spitting  some  blood. 
On  admission,  September  27,  1894,  he  is  a  thin,  delicate-looking  boy,  with  clubbed 
fingers.  On  examination  of  the  chest :  the  right  side  has  a  boxy  note,  except  at  the  base, 
behind  which  is  dull ;  the  breath  sounds  are  very  faint ;  some  friction  sounds  in  the  axilla  ; 
the  left  side  is  normal,  except  that  the  breath  sounds  are  exaggerated.  There  is  not  much 
d3'spnoea,  but  he  is  subject  to  paroxysms  of  coughing,  when  he  brings  up  considerable 
quantities  of  very  foetid  pus.  October  2. — Paroxysms  of  coughing  and  foetid  expectora- 
tions ;  som.e  dulness  at  left  base  behind.  Coarse  crepitation  anteriorly  on  right  side. 
Explored  right  side  subcutaneously  in  several  different  places,  but  failed  to  find  pus. 
October  3. — Much  collapse.     Death  October  6. 

Post-mortem. — Right  lung  adherent  in  front,  in  axillary  region  pyopneumothorax  ; 
pus  very  foul ;  small  cavity  in  middle  of  lobe,  communicating  with  bronchus  and  also 


Ple2trisy  mid  Eiiipyenui  375 

pleural  cavity  ;  patches  of  consolidation  throughout  the  lung  becoming  gangrenous  ;  no 
definite  tubercle.  Left  lung  adherent  behind;  recent  pleurisy.  Heart  and  other  organs 
show  nothing  abnornial. 

Abscess   of  the  Iiung: 

Purulent  collections  in  the  lungs  are  mostly  the  result  of  septic  embolism 
from  some  distant  suppurating  centre,  as  in  an  otitis  or  some  other  bone 
lesion,  and  are  associated  with  pyiemia.  They  are  usually  small  and  situated 
on  the  surface.  Small  abscesses  may  be  secondary  to  an  empyema,  the  latter 
finding  its  way  w«  a  small  abscess  into  a  bronchial  tube.  Minute  abscesses 
are  sometimes  a  sequence  of  a  broncho-pneumonia  secondary  to  scarlet 
fever,  measles,  or  whooping  cough,  suppuration  taking  place  in  the  lobules 
immediately  surrounding  the  terminal  bronchioles  ;  here  small  centres  con- 
taining pus  may  be  found  (see  p.  360). 

In  both  gangrene  and  abscess  of  the  lung,  if  the  lesions  are  fairly 
locahsed,  or  the  disease  progressing,  an  attempt  should  be  made  to 
arrest  the  mischief  by  incising  and  draining  the  abscess  or  gangrenous 
cavity.  For  this  purpose  it  is  necessary  to  locaUse  the  abscess,  first  by  the 
physical  signs  as  far  as  may  be,  and,  secondly,  by  exploration  with  an 
aspirator  needle,  though,  if  the  evidence  is  otherwise  strong,  failure  to  draw- 
off  pus  by  the  aspirator  should  not  prevent  a  further  exploration  ;  the  incision 
should  be  made  over  the  abscess,  and,  if  necessary,  one  or  more  segments 
of  rib  removed  ;  the  lung  should  then  be  incised  and  drained,  and  treated  on 
ordinary  surgical  principles.  We  have  incised  and  drained  a  hydatid  of  the 
lung  and  a  pulmonary  abscess,  with  considerable  relief  to  the  children  in  each 
instance. 

Pleurisy   and   Empyema 

That  pleurisy  must  be  a  common  disease  in  children  is  shown  by  the 
frequency  with  which  the  lungs  are  found  adherent  to  the  chest  walls  when 
making  autopsies  on  children  who  have  died  from  various  diseases  Here, 
as  in  the  case  of  adults,  the  evidence  of  a  past  pleurisy  is  conclusive.  Yet  it 
cannot  be  said  that  pleurisy  is  diagnosed  and  treated  with  any  great 
frequency- during  life,  the  reason  no  doubt  being  that  young  children  are  not 
able  to  localise  attacks  of  pain,  that  when  fretful  it  is  not  easy  to  thoroughly 
examine  their  chests  by  auscultation,  and,  moreover,  the  symptoms  may  be 
masked  by  other  diseases  in  which  the  pleural  lesion  plays  but  a  secondary 
part. 

Pleurisy,  primary  and  acute,  occurs  at  all  ages  during  infancy  and  child- 
hood, the  first  year  of  life  being  by  no  means  exempt.  It  is  apt  to  follow 
exposure  to  cold,  or,  not  infrequently,  an  accident,  such  as  a  fall  or  blow  on 
the  chest.  It  is,  however,  far  more  commonly  associated  with  a  croupous, 
catarrhal,  or  septic  pneumonia.  It  occurs  very  frequently  in  connection  with 
tuberculosis  of  the  lung. 

Symptoms. — Pleurisy  may  begin  suddenly  and  run  an  acute  course,  though 
more  often  it  is  subacute.  The  attack  begins  with  a  short  cough,  fever, 
shallow  respiratory  movements,  the  affected  side  moving  less  than  its  fellow, 
accompanied  by  sharp  pain,  which  the  child,  if  old  enough  to  do  so,  refers  to 
the  side  or  very  often  the  epigastrium.     In  infants  the  attack  m.y  be  ushered 


3/6  Diseases  of  the  Respiratory  Apparatus 

in  by  convulsions  and  its  course  may  be  marked  by  screaming  fits,  especially 
if  the  child  is  disturbed.  If  the  pleurisy  is  extensive  and  acute,  an  examina- 
tion of  the  chest  shows  the  respirations  to  be  shallow,  and  the  movements  of 
the  affected  side  extremely  limited,  while  percussion  or  pressure  in  the 
intercostal  spaces  with  the  finger  gives  rise  to  expressions  of  acute  pain. 
On  auscultation,  while  the  breath  sounds  are  loud  and  clear  on  the  normal 
side,  they  are  weak  on  the  affected,  and  perhaps  accompanied  by  a  friction 
sound.  The  pulse  is  quickened  and  there  is  fever,  perhaps  ioo°  to  102°, 
unless  pneumonia  is  present,  when  it  is  probably  higher.  The  further  course 
of  the  attack  varies  according  to  whether  effusion  of  serum  occurs  or  not. 
In  the  latter  case,  in  the  course  of  a  few  days  the  fever  subsides,  the  friction 
sounds  disappear,  though  perhaps  some  '  stitch '  (stabbing  pain  in  the  side) 
remains  for  a  while.  In  many  cases  apparently  a  local  pleurisy  takes  place 
during  the  course  of  a  bronchitis  or  bronchial  catarrh  in  which  little  else 
than  a  sharp  pain  in  the  side  or  abdomen  is  present. 

In  pleurisy  occurring  between  the  diaphragm  and  lung  the  symptoms  are 
generally  obscure,  there  is  pain  and  tenderness  in  the  epigastric  or  hepatic 
region,  with  thoracic  breathing,  the  abdominal  muscles  and  diaphragm  being 
kept  as  quiet  as  possible.  Should  effusion  take  place  in  any  quantity, 
signs  of  its  presence  quickly  appear.  The  child  will  probably  lie  on  the 
affected  side,  so  as  to  give  full  play  to  the  lung  on  the  sound  side  ;  the  infant, 
as  Henoch  points  out,  with  fluid  in  the  right  pleural  cavity  takes  only  the  left 
breast  of  its  mother  for  a  similar  reason.  On  inspection  it  will  be  noted  that 
the  side  containing  the  effused  fluid  moves  less  freely  than  the  other,  and  if 
the  fluid  is  in  the  left  chest,  the  cardiac  impulse  is  displaced  towards  the 
right  side.  In  large  pleural  effusions  on  the  right  side  the  impulse  may 
be  moved  towards  the  left.  This  displacement  of  the  cardiac  impulse  is 
of  special  value  in  the  diagnosis  of  fluid  in  the  chest  in  children,  on  account 
of  the  uncertainty  and  small  value  of  some  of  the  other  physical  signs  ; 
as,  for  instance,  the  vocal  resonance  and  fremitus,  which  yield  valuable  in- 
formation in  adults.  The  position  of  the  heart's  impulse  is  best  ascertained 
by  placing  the  surface  of  the  hand  on  the  chest  wall,  and,  if  necessary,  by 
determining  by  auscultation  the  position  of  the  heart  by  the  comparative 
loudness  of  its  sounds.  It  is  necessary,  however,  to  remember  that  the  heart 
may  be  displaced  without  any  fluid  being  present  at  the  time  of  examination, 
as  it  may  have  been  pushed  on  one  side  by  a  former  effusion  and  have  become 
fixed  in  an  abnormal  position  by  fibrous  adhesions  ;  in  this  case  the  lung  also 
will  probably  be  adherent,  and  a  dull  note  may  be  elicited  over  it  which 
suggests  the  presence  of  fluid.  The  heart  may  also  be  pulled  on  one  side  or 
upwards  by  a  fibroid  condition  of  lung  or  chronic  pleurisy. 

On  percussion  of  the  chest,  a  dull  or  much  impaired  resonance  will  be 
detected  over  the  area  occupied  by  fluid,  while  in  most  cases  the  sub- 
clavicular region  and  frequently  also  the  supra-spinous  fossa  and  possibly  a 
strip  between  the  base  of  the  scapula  and  the  spine  will  be  resonant,  often 
hyper-resonant.  If  the  effusion  is  great  the  whole  side  will  be  completely 
dull  and  give  a  sense  of  resistance  on  percussion.  On  auscultation  the 
breath  sounds  are  weak  and  distant,  but  usually  of  a  distinctly  bronchial  or 
tubular  character.  In  the  earlier  stages  of  effusion  the  expiratory  murmur 
is  especially  accentuated  and  bronchial,  the  air  from  the  compressed  lung 


Pleurisy  377 

being,  as  it  were,  expelled  with  ditliculty.  The  breath  sounds  on  the  healthy 
side  are  exaggerated.  The  vocal  resonance  and  fremitus  may  be  absent  or 
weak,  but  it  may  be  impossible  to  elicit  any  information  in  this  way,  as  the 
voices  of  children,  especially  girls,  are  weak,  and  moreover  they  may  not  be 
old  enough  to  understand  what  they  are  wanted  to  do.  During  crying,  in- 
formation of  value  may  sometimes  be  obtained  by  placing  the  hand  on  the 
chest.  Comparative  measurements  of  the  two  sides  show  the  affected 
side  in  recent  cases  to  be  larger  than  the  other  ;  but  too  much  value  must 
not  be  attached  to  measurements,  as  in  chronic  cases  some  amount  of  re- 
traction may  have  taken  place.  Of  more  value  is  the  cyrtometer  tracing  ; 
this,  as  pointed  out  by  Dr.  S.  Gee,  shows  a  change  of  shape  from  the 
elliptical  to  the  more  circular  form  without  the  circumference  necessarily 
being  increased. 

Should  a  large  amount  of  fluid  be  poured  out  in  a  short  space  of  time,  it 
will  necessarily  give  rise  to  dyspnoea  :  the  child  will  turn  over  on  to  the 
atTected  side  or  lie  upon  its  back  ;  the  alae  nasi  work,  and  the  number  of  re- 
spirations is  increased  perhaps  to  forty  or  fifty.  If  the  amount  of  fluid  is 
smaller  in  quantity,  the  child  may  be  tolerably  comfortable  while  lying  at 
rest,  but  there  is  dyspnoea  on  the  slightest  exertion.  The  amount  of  feverish- 
ness  varies  ;  during  the  inflammatory  stage  before  or  during  the  period  the 
serum  is  being  poured  out  the  temperature  is  usually  raised  two  or  three 
degrees  ;  in  the  course  of  a  few  days  a  gradual  fall  takes  place,  and  there  may 
be  no  fever  or  only  a  slight  elevation  at  night. 

Under  favourable  circumstances  in  a  healthy  child,  the  serum  effused 
begins  to  be  reabsorbed  :  this  it  usually  does  in  the  course  of  a  few  days, 
the  heart  if  displaced  returning  by  degrees  to  its  normal  position,  the  level  of 
the  fluid  becominglowerand  lower,  till  the  side  regains  its  normal  resonance  ; 
or,  what  is  much  more  likely,  a  somewhat  impaired  resonance,  which  it  retains 
for  many  weeks.  The  reason  of  this  is  doubtless  that  the  re-expanded  lung 
remains  for  some  time  in  a  sodden  and  congested  state,  and  not  improbably 
its  pleural  surface  contracts  adhesions  with  the  chest  wall.  During  the 
stage  of  reabsorption  friction  and  moist  rales  are  frecjuently  heard  in  the 
lung,  and  the  breath  sounds  are  weak.  In  some  cases,  however,  this  desirable 
reabsorption  does  not  at  once  take  place.  The  child's  health  is  impaired, 
he  is  antemic  and  depressed,  perhaps  thick  layers  of  lymph  are  covering  the 
pleural  surface  of  the  lung  and  chest  wall,  and  conditions  are  not  favourable 
for  the  reabsorption  of  the  fluid  after  the  inflammation  has  subsided  ;  or 
possibly  the  absorption  may  go  on  e^jtremely  slowly,  pari  passu  with  the 
organising  of  the  lymph  which  has  been  poured  out.  Under  these  circum- 
stances much  damage  may  be  done,  the  heart  may  be  fixed  in  a  malposition, 
the  lung  may  become  tied  down  by  a  thick  layer  of  fibroid  tissue  which, 
contracting,  holds  the  lung  in  its  grip,  while  the  chest  falls  in  and  the  spine 
becomes  curved. 

But  besides  a  quick  reabsorption  of  the  serum,  and  a  chronic  pleurisy 
with  its  slow  course,  another  result  may  follow,  and  that  is — at  least  this 
is  what  is  usually  believed— the  serum  may  become  pus  ;  this,  however,  is  not 
a  common  result  if  the  fluid  effused  is  at  first  serum,  and  it  rarely  happens 
that  it  remains  so  for  some  weeks  and  then  finally  becomes  converted  into 
pus.     An  empyema,  as  a  rule,  is  an  empyema  from  the  first,  at  least  the  fluid 


T^yS  Diseases  of  the  Respiratory  Apparatus 

effused  is  turbid-looking  at  first ;  in  other  words,  it  is  thin  pus,  and  later  it 
becomes  thick  pus.  It  is  no  doubt  most  common  to  find  that  where  there  is 
reason  to  believe  fluid  has  existed  in  the  chest  for  some  weeks  or  months, 
the  fluid  is  pus  and  not  serum,  but  then  in  all  probability  the  fluid  has  been 
pus  from  the  first  and  has  failed  to  be  absorbed,  whereas  had  it  been  serum 
it  would  have  been.  Serum  may  undoubtedly  remain  in  the  chest  unaltered 
for  many  weeks,  perhaps  months  ;  but  this  is  uncommon  except  in  cases  of 
tubercle,  or  new  growths  in  the  lung,  or  in  cardiac  disease.  An  empyema  is, 
in  the  vast  majority  of  instances  at  any  rate,  the  result  rather  of  a  pleuro- 
pneumonia than  a  simple  pleurisy.  The  more  intense  the  inflammation 
the  more  likely  it  is  that  pus,  not  simple  serum,  is  poured  out,  or  that 
the  serum  poured  out  quickly  becomes  pus.  This  is  especially  likely  to 
happen  if  a  pleuro-pneumonia  follows  scarlet  fever,  measles,  or  whooping 
cough,  or  indeed  any  pneumonia  of  the  croupous  type.  The  symptoms  given 
by  an  empyema  are  by  no  means  distinctive  as  between  pus  and  serum,  and 
often  no  definite  diagnosis  can  be  arrived  at  until  an  exploratory  puncture 
has  been  made.  In  favour  of  pus  in  acute  cases  would  be  the  occurrence  of 
pleurisy  as  a  sequel  of  a  zymotic  disease,  especially  in  a  weakly  child  ;  in 
chronic  cases  the  presence  of  hectic,  diarrhoea,  a  sallow  earthy  complexion, 
the  '  pointing  '  of  a  collection  of  fluid  in  connection  with  the  chest.  A  collec- 
tion of  purulent  fluid  may  be  present  in  the  chest  and  give  very  few  signs  of 
its  presence,  except  the  physical  signs.  It  must  be  remembered  that  in  any 
chronic  case  of  fluid  in  the  chest  in  a  child,  that  fluid  is  probably  pus,  but  not 
universally  so.  The  early  history  of  an  empyema  is  generally  that  of  an 
acute  pneumonia  which  does  not  clear  up,  and  the  presence  of  pus  in  the 
chest  is  likely  to  be  thought  to  be  consolidation  of  the  lung,  especially  as 
there  may  be  Avell-marked  bronchial  breathing.  As  an  illustration  of  this 
the  following  case  may  be  cited. 

A  girl  of  nine  years  was  convalescent  from  scarlet  fever.  On  the  thirty-eighth  day  the 
temperature  rose  to  105",  there  was  intense  pain  referred  to  the  left  side  of  the  chest  and 
epigastrium,  especially  felt  when  she  turned  in  bed,  there  was  also  some  want  of  resonance 
at  the  left  apex.  On  the  third  day  of  the  attack  there  was  diminished  resonance  over  the 
whole  left  side,  with  bronchial  breathing  ;  no  displacement  of  the  heart.  On  the  sixth  day 
there  was  slight  displacement  of  the  heart  to  the  right,  the  dulness  over  the  left  chest  was 
much  more  marked,  the  breath  sounds  ^vere  faint  and  bronchial.  On  the  eleventh  day 
the  signs  of  fluid  had  increased,  the  heart's  impulse  being  felt  at  the  left  border  of  the 
sternum  ;  an  exploratory  puncture  showed  the  presence  of  pus.  On  the  seventeenth  day 
the  chest  was  incised  antiseptically,  pus  and  much  lymph  escaped,  a  tube  was  inserted, 
and  complete  recovery  ensued  (see  fig.  72). 

It  must  always  be  borne  in  mind  if  a  croupous  pneumonia  does  not  clear 
up  and  the  dulness  disappear,  or  if  the  temperature  remits  instead  of 
falling  when  the  time  for  a  crisis  comes,  pus  may  be  present  in  the  chest. 
In  such  cases  the  signs  of  consolidation  of  lung  are  gradually  replaced  by 
those  of  fluid,  the  latter  accumulating  as  the  pneumonic  consolidation  dis- 
appears. 

Pus  may  be  present  in  the  chest,  yet  not  free  in  the  pleural  cavity,  but 
confined  by  adhesion  between  the  lung  and  chest  wall  or  diaphragm.  More 
than  one  localised  empyema  may  be  present  on  the  same  or  opposite  sides. 
Such  localised  collections  may  be  present  in  any  part,  as  at  the  apex  in  front,, 


Empyema 


379 


the  Ijase  beliind,  or  in  front  between  tlie  pericardium  and  anterior  edge  of 
the  left  lung,  or  between  the  lung  and  the  diaphragm.  We  have  known  a 
localised  empyema  situated  at  the  posterior  side  of  the  apex  of  one  lung  ; 
there  was  fairly  good  resonance  in  front  and  behind,  except  over  asmallarea 
at  the  back  of  the  apex  of  the  lung.  These  small  empyemas  are  often  asso- 
ciated with  broncho-pneumonias  and  chronic  tuberculosis  of  the  lung.  It  is 
perfectly  obvious  that  if  these  collections  of  fluid  are  not  large  and  are  sur- 
rounded by  and  backed  up  by  crepitant  lung,  diagnosis  will  be  by  no  means 
easy,  and  it  is  not  surprising  that  such  should  be  found  on  the  post-mortem 
table,  havingescaped  discovery  during  life.  In  these  cases  the  physical  signs 
are  not  distinctive  ;  there  will  mostly  be  a  patch  of  dulness,  with  more  or 
less  resistance,  but  an  adherent  lung  with  thick  fibroid  tissue  between  it  and 
the  chest  wall  will  give  a  similar  note.     The  breath  sounds  are  weak,  perhaps 


IBBRslsiisiBBisiEsBBBSBssiislillisiiiiisii 


l55BBBBBiB5B5B555555555555555B5BB53EBBa5ai§ 


Fig.  72. — Temperature  Chart  of  a  case  of  Pleuro-pneumonia  followed  by  Empyema,  in  a  girl  of 
nine  years.  Signs  of  fluid  were  discovered  on  the  sixth  day,  pus  on  the  eleventh  day;  on  the 
seventeenth  day  the  chest  was  incised,  followed  by  a  fall  in  the  temperature. 


bronchial.  When  in  doubt  it  is  wise  to  explore,  not  using  too  fine  a  needle, 
as  if  the  bore  is  too  small  it  is  apt  to  become  blocked  with  a  flake  of  lymph 
or  pus.  If  the  layer  of  pus  is  not  thick  the  needle  may  pass  through  the  pus 
into  lung  beyond. 

Diagnosis. — The  distinction  between  the  consohdation  of  pneumonia  and 
pleuritic  effusion  in  typical  cases  is  made  readily  enough.  The  intense 
bronchial  breathing,  with  the  clear,  ringing  rales  and  impaired  resonance  of 
pneumonic  consolidation,  form  a  marked  contrast  to  the  weak,  distant  breath 
sounds,  wooden  dulness,  and  displaced  heart  distinctive  of  a  large  effusion 
of  fluid.  In  many  cases,  however,  no  diagnosis  is  possible  without  an  ex- 
ploratory puncture,  and  even  then  a  negative  result  does  not  definitely  settle 
the  matter,  as  it  is  c|uite  possible  to  miss  the  fluid.  A  pneumonic  lung 
covered  with  a  thick  layer  of  lymph,  or  a  sodden  lung  covered  with  fibroid 
tissue  and  adherent  to  the  chest  wall,  gives  a  wooden  dulness  and  resistance 


380  Diseases  of  tJie  Respiratory  Apparattis 

closely  resembling  that  of  fluid.  On  the  other  hand,  when  fluid  is  present 
the  bronchial  breathing  is  sometimes  loud  and  even  intense.  A  good  rule 
to  follow  is,  whenever  there  is  a  patch  of  dulness  that  does  not  clear  up, 
especially  where  there  is  a  hectic  or  elevated  temperature,  always  to  explore 
by  means  of  a  subcutaneous  syringe.  The  diagnosis  between  a  local  or 
small  collection  of  fluid  at  a  base  and  chronic  pneumonia,  caseous  pneumonia 
and  tubercular  consolidation,  is  often  far  from  easy,  and  indeed  is  generally 
impossible  without  exploration.  There  may  be  dulness  and  a  hectic  tem- 
perature, moreover  there  may  be  a  patch  of  impaired  resonance  in  the  axilla 
while  the  apex  and  base  are  resonant,  or  both  sides  may  be  affected. 

In  one  of  our  cases  there  was  intense  bronchial  breathing  and  increased 
vocal  resonance  over  the  whole  of  the  right  lung,  except  at  the  base  ;  it 
was  very  dull  all  over.  We  removed  7  oz.  of  pus  and  more  drained  away 
afterwards. 

Morbid  Anatomy. — It  is  not  often  that  an  opportunity  occurs  of  examin- 
ing the  chest  of  a  child  that  has  died  of  uncomplicated  pleurisy  or  empyema, 
though  it  is  common  enough  to  find  both  in  association  with  pneumonia  or 
tuberculosis.  The  pleurisy  differs  much  in  degree,  from  a  simply  roughened 
surface  to  a  layer  of  thick  lymph  ;  the  adhesions  which  result  from  the 
organising  of  the  lymph  also  varying  greatly  in  toughness  and  thickness. 
Serum  in  varying  amount,  perhaps  in  greater  quantity  than  was  suspected 
during  life,  may  be  found  in  association  with  pneumonia,  especially  in  such 
diseases  as  nephritis,  septicemia,  and  scarlet  fever.  The  lung  corresponding 
to  the  position  of  the  fluid  is  collapsed  and  airless.  The  result  of  a  past 
pleurisy,  especially  when  this  has  been  chronic,  is  sometimes  seen  at  the/<9.5-/- 
inortem  in  the  shape  of  thick  fibroid  adhesions  which  completely  surround 
and  infiltrate  the  lung.  The  latter  is  completely  adherent,  airless,  in  a 
condition  of  cirrhosis,  traversed  by  bands  of  fibroid  tissue,  and  occupying  a 
position  at  the  posterior  aspect  of  the  chest  in  contact  with  the  spine.  In 
other  cases  there  may  be  found  adhesions  connecting  both  lungs  with  the 
chest  wall  and  diaphragm,  and  on  cutting  through  the  lungs  they  appear  to 
be  riddled  with  cavities,  which  are  in  reality  dilated  bronchial  tubes.  The 
relation  between  empyemas  and  tuberculosis  is  interesting  and  important.  It 
is  believed  by  some  that  the  subjects  of  chronic  empyemas  are  apt  to  become 
tubercular  ;  in  other  words,  patients  who  suffer  from  a  chronic  empyema  are 
likely  to  die  of  phthisis.  We  do  not  think,  at  least  as  far  as  our  experience 
goes,  that  there  is  2cay  post-inortem  evidence  to  support  this.  That  chronic 
pneumonia  may  terminate  in  tuberculosis  by  the  mediastinal  glands  becoming 
caseous  is  an  almost  every-day  experience,  but  this  certainly  does  not  apply 
to  empyema.  Barlow  and  Parker,  however,  state  that  they  have  met  with 
cases  where  they  believed  atuberculosis  was  secondary  to  a  chronic  empyema. 
Localised  collections  of  pus  may  sometimes  be  found  in  connection  with 
chronic  tuberculosis,  but  in  these  cases  the  pus  is  apparently  secondary  to  the 
tubercular  process. 

Suppurative  or  simple  pericarditis  may  take  place  by  extension  of  the 
inflammation  from  the  pleura. 

Treatment. — In  the  early  stages  of  dry  pleurisy,  where  the  pain  is  severest, 
the  child  is  necessarily  placed  in  bed,  small  doses  of  an  anodyne  being  given, 
and  hot  applications  applied  to  the  chest.     Small  doses  of  opiates  relieve  the 


Treatment  of  Pleurisy  and  Empyema  381 

]jain  best,  such  as  Dover's  powder  ox  -^--^  grain  of  morphia  given  sub- 
tut.'ineously  ;  the  latter  may  be  administered  to  children  over  four  years,  but 
not  to  infants.  Hot  poultices  may  be  used  with  less  fear  than  in  pneumonia 
\\  here  much  lung  is  involved.  Strapping  the  chest  on  the  affected  side  with 
strips  of  belladonna  plaster  is  often  very  useful. 

The  natural  course  of  a  dry  pleurisy  is  towards  recovery,  the  inflamma- 
tory condition  of  the  pleura  subsiding,  the  lymph  effused  being  organised, 
and  the  lung  becoming  adherent  to  the  chest  wall.  The  adhesions  thus 
formed  differ  very  much  in  their  firmness  and  strength,  the  lung  being 
perhaps  only  loosely  attached  to  the  parietes,  so  that  its  movements  are  only 
slightly  if  at  all  impaired,  or  firmly  attached  by  thick  leathery  adhesions, 
so  that  it  cannot  be  torn  away  without  damage.  In  the  latter  case  the  ad- 
hesions are  extensive,  the  movements  of  the  lung  are  impaired,  it  never 
properly  empties  itself  of  air,  and  it  is  in  consequence  always  more  or  less 
in  a  congested  or  cedematous  condition,  and  possibly  becomes  infiltrated  with 
fibroid  tissue  while  the  bronchial  tubes  become  dilated.  Such  cases  are 
probably  the  result  of  chronic  or  subacute  pleurisy  ;  the  chest  may  also  con- 
tract and  fall  in.  When  an  effusion  of  fluid  has  occurred,  in  the  vast 
majority  of  cases  reabsorption  takes  place  after  the  inflammatory  condition 
of  the  pleura  has  subsided,  and  the  tension  of  blood  in  the  vessels  has  become 
reduced  to  normal.  Life,  however,  may  be  threatened  from  the  excess  of  fluid 
thrown  out  ;  under  these  circumstances  nearly  the  whole  of  the  blood  in  the 
body  is  passing  through  the  sound  lung  ;  it  is  consequently  intensely  con- 
gested, and  may  become  oedematous,  Moreover,  the  right  side  of  the  heart 
is  over-distended,  and  as  a  consequence  sudden  death  is  apt  to  ensue.  For 
this  reason  no  time  should  be  lost,  if  the  dyspnoea  and  distress  become  great, 
in  relieving  the  chest  by  the  withdrawal  of  some  of  the  effused  fluid.  On  the 
other  hand,  the  mere  presence  of  fluid  in  the  chest,  if  there  are  no  signs  of 
distress,  does  not  necessitate  operative  interference,  as  in  the  great  majority 
of  cases  absorption  takes  place  in  the  course  of  a  few  days  or  a  week.  Opera- 
tive interference,  therefore,  is  called  for  in  all  cases  where  there  is  dyspnoea 
or  orthopnosa  when  lying  quietly  in  bed,  or  where  there  is  much  displacement 
of  the  heart.  In  those  chronic  cases  where  the  fluid  is  not  absorbed  or  is  not 
diminishing  in  quantity  after  the  lapse  of  a  few  weeks,  the  serum  maybe 
removed  from  the  chest  by  means  either  of  the  aspirator  or  by  trocar  and 
cannula,  the  small  ones  introduced  by  Dr.  Southey  for  the  removal  of  the 
fluid  in  ascites  answering  very  well.  Whatever  method  is  selected,  the  fluid 
should  be  removed  slowly,  and  there  is  no  necessity  to  remove  all  that  can 
be  aspirated.  Too  rapid  aspiration  of  the  fluid  is  apt  to  lead  to  bleeding 
into  the  chest  from  rupture  of  some  of  the  capillary  vessels,  and  may  possibly 
cause  emphysema  of  the  lung  on  account  of  one  part  of  the  lung  expanding 
faster  than  the  other.  On  the  whole,  we  believe  the  best  results  are  obtained 
by  the  use  of  Southey's  trocar  and  cannula.  One  of  these  maybe  introduced 
without  difficulty  and  without  pain  if  local  anaesthesia  be  produced,  a  piece  of 
fine  india-rubber  tube  attached,  and  the  fluid  allowed  slowly  to  drain  away 
for  a  couple  of  hours  or  so,  10  to  20  ozs.  being  thus  withdrawn  ;  if  neces- 
sary two  cannula;  can  be  inserted.  In  those  cases  where  the  dyspnoea 
is  extreme,  relief  is  more  quickly  obtained  by  aspiration.  It  may  not  im- 
probably happen  that  the  pleural  cavity  in  part  fills  up  again  and  a  second 


382  Diseases  of  the  Respiratory  Apparatus 

or  a  third  removal  be  required.  In  the  less  acute  cases,  where  there  is  no 
urgency  and  no  removal  is  attempted,  the  child  should  be  confined  to  bed  in 
a  warm  room  and  carefully  protected  from  cold.  It  may  be  doubted  if  any 
drug  materially  aids  the  reabsorption  of  the  effused  fluid,  though  the  usual 
treatment  in  such  cases — namely,  giving  iodide  of  potassium  internally  and 
painting  liniment  of  iodine  mixed  with  an  equal  quantit)^  of  glycerine  exter- 
nally— appears  to  be  useful.  The  lin.  iodi  by  itself  requires  using  with  care, 
especially  in  young-  or  weakly  children. 

The  natural  cause  of  an  empyemji  differs  from  that  of  a  simple  serous 
effusion.  In  a  minority  of  cases,  especially  where  the  empyema  is  small 
and  confined  by  adhesions,  it  may  dry  up,  and  the  inspissated  pus  in  time 
become  cretaceous.  But  this  event  can  hardly  be  expected,  and  should  it 
take  place,  especially  if  the  empyema  be  a  large  one,  the  result,  accompanied 
as  it  is  by  retraction  of  the  chest  and  compression  of  the  lung,  is  anything 
but  satisfactory.  The  presence  of  pus  in  the  chest  is  inconsistent  with  good 
health,  to  say  nothing  of  the  risks  the  patients  run  of  its  burrowing  in  various 
directions.  The  child  with  a  chronic  undrained  empyema  probably  suffers 
from  hectic  fever,  is  anccmic  and  sallow,  the  skin  becomes  rough,  the  fingers 
clubbed,  and  the  child  emaciates.  Various  other  results  may  follow  :  the 
pus  may  find  its  way  through  the  intercostals,  and  point  in  the  fourth  or 
fifth  space,  it  may  then  gradually  undermine  the  skin  and  a  chronic 
discharge  take  place.  It  may  open  through  the  lung  into  a  bronchial  tube 
and  be  gradually  coughed  up  ;  in  this  way  recovery  may  eventually  take 
place,  though  the  process  is  a  slow  one  ;  or  an  abscess  or  abscesses  may 
form  in  the  lung.  An  empyema  on  the  right  side  may,  either  by  con- 
tiguity or  by  opening  through  the  diaphragm,  give  rise  to  an  abscess  in  the 
liver.  It  may  open  into  the  abdomen  by  finding  its  way  through  the  diaphragm, 
and  set  up  peritonitis.  The  pus  may  burrow  any  distance,  opening  through 
the  abdominal  walls  or  simulating  a  lumbar  abscess. 

Directly  a  diagnosis  of  pus  in  the  chest  is  made,  arrangements  should  be 
made  to  evacuate  it,  and  this  in  the  vast  majority  of  cases  should  be  by  free 
incision  and  drainage.  Aspiration  may  be  tried  once  or  twice  in  local 
empyemata,  especially  in  infants-  and  small  children  ;  but  it  is  only  in  the 
minority  of  cases  that  it  will  succeed,  as  the  cavity  usually  fills  up  again 
and  separates  the  parts  which  should  be  kept  in  contact  if  a  cure  is  to  result. 

The  surgical  treatment  of  suppuration  within  the  pleural  cavity  is  based 
on  the  ordinary  principles  guiding  us  in  the  management  of  abscesses  else- 
where. Hence,  although  it  occasionally  happens  that  pleural  abscesses  dry 
up  and  do  not  discharge  at  all,  or  discharge  through  the  lung  or  elsewhere 
and  then  heal,  none  of  these  possibilities  should  be  looked  for,  and  the  treat- 
ment practically  resolves  itself  into  tapping  and  free  incision. 

Tapping  an  empyema  with  a  simple  trocar  and  allowing  the  fluid  to  drain 
away  through  a  tube  into  an  antiseptic  lotion  is  a  mode  of  treatment  that 
is  successful  in  certain  cases,  but  is  open  to  several  objections.  The  cases 
for  which  it  is  suitable  are  those  where  the  empyema  is  recent,  of  small  size, 
contains  no  masses  of  lymph  or  caseous  material,  and  where  the  lung  is  not 
bound  down  by  firm  adhesions  but  is  ready  to  expand  on  removal  of  the  com- 
pressing fluid  ;  further,  it  is  important  for  the  successful  employment  of  this 
plan  that  the  pus  be  contained  in  one  cavity  only  and  not  be  loculated.    The 


Treatment  of  Plcjirisy  and  Empyema  383 

dangers  of  tapping  are  the  risk  of  wounding  the  King  by  thrusting  the  trocar 
too  far  inwards  on  the  one  hand,  and  on  the  other  the  possibihty  of  pushing 
the  thickened  pleura  or  a  hiyer  of  lymph  before  the  trocar  so  that  the 
abscess  cavity  is  not  opened.  There  is  also  the  likelihood  of  the  cannula 
becoming  blocked  with  lymph  or  caseous  material,  and  of  incomplete 
emptying  of  the  cavity  because  it  is  loculatcd  or  because  the  lung  cannot 
re-expand. 

Aspiration  is  open  to  the  same  objections,  with  the  additional  one  that 
if  too  powerful  suction  is  employed  there  is  likely  to  be  bleeding  from  the 
surface  of  the  lung  or  the  pleura,  and  the  cavity  may  become  partially  filled 
with  clot  which  readily  decomposes. 

The  difficulty  of  emptying  the  cavity  when  the  lung  cannot  re-expand  has 
been  met  by  Mr.  R.  W.  Parker  by  the  plan  of  injecting  aseptic  air  into  the 
pleura  to  replace  the  pus  as  it  flows  away,  or  lotions  may  be  used  with  the 
same  object  ;  but  the  plan  has  not  met,  and  is  not  likely  to  meet,  with  general 
approval.  Aspiration,  then,  should  be  employed  for  small,  single,  recent 
empyemata,  and  in  some  few  of  such  cases  after  one  or  two  tappings  the  pus 
will  cease  to  be  secreted.  Should  there  be  chronic  disease  of  the  lung, 
caseous  material,  glandular  or  other,  or  disease  of  the  ribs  or  spine,  since  the 
source  of  irritation  remains,  pus  formation  will  go  on  and  aspiration  cannot 
be  sufficient.  Failing,  then,  tapping  or  aspiration,  the  remaining  resource 
is  free  incision  and  drainage  of  the  abscess.  The  general  plan  of  operation 
may  be  described  first,  and  certain  special  points  alluded  to  afterwards. 

The  incision  should  be  an  inch  or  more  in  length,  and  should  be  made 
along  the  lower  margin  of  the  space  selected,  so  as  to  avoid  injury  to  the 
intercostal  vessels.  The  tissues  should  be  gradually  cut  through  until  the 
pleura  is  reached,  all  bleeding  being  arrested  before  the  pleura  is  opened. 
If  the  membrane  is  not  much  thickened,  a  sharp  director  may  be  thrust 
through  it  and  used  as  a  guide  for  the  knife  ;  if,  however,  it  is  very  tough 
and  thick,  as  may  be  the  case  if  the  disease  is  of  long  standing,  it  is  better  to 
incise  it  at  once  with  the  knife.  As  soon  as  the  cavity  is  reached  a  pair  of 
dressing  or  sinus  forceps  should  be  passed  in,  opened,  and  the  pus  allowed 
to  escape  freely.  The  drainage  tube  is  then  to  be  inserted  and  secured  by 
a  thread  round  the  chest  unless  a  special  tube  is  employed.  Possibly  the 
dressings  wnll  be  soaked  and  require  changing  in  a  few  hours  ;  if,  however, 
the  cavity  is  fairly  emptied  and  diick  wood-wool  pads  are  employed,  this  is 
not  likely  to  be  the  case. 

The  special  points  to  be  considered  are  the  position  of  the  incision,  the 
drainage  tube,  the  management  of  adhesions,  and  the  washing  out  of  the  chest. 
First,  then,  the  position  of  the  incision.  Where  the  empyema  is  local  the 
incision  must  of  course  be  made  over  it,  and  the  lowest  convenient  spot  for 
drainage  should  be  chosen.  Where  the  whole  pleural  cavity  is  filled  with 
pus  a  difference  of  opinion  exists  as  to  the  most  suitable  spot  for  the  opening. 
Mr.  Marshall  advocated  an  incision  in  the  front  of  the  chest,  others  prefer 
the  axilla.  We  think,  however,  on  the  whole,  the  best  place  is  just  behind 
and  below  the  angle  of  the  scapula  in  the  eighth  interspace — this  spot 
affords  good  drainage  when  the  patient  lies  on  his  back  or  side  ;  it  is  not 
cjuite  so  convenient  for  dressing,  but  it  is  nearly  at  the  lowest  point  of  the 
cavity,  yet  not  so  low  as  to  risk  injury  to  the  diaphragm,  which  is  liable  to  be 


384  Diseases  of  the  Respiratory  Apparatus 

drawn  up  to  take  the  place  of  the  shrunken  lung.^  Unless  the  incision  is 
made  too  far  back  there  is  no  great  thickness  of  muscle  to  cut  through. 

As  to  drainage,  though  in  some  cases  where  the  chest  is  very  full  of 
fluid  the  intercostal  spaces  may  be  widened  and  bulging,  yet  much  more  often 
this  is  not  so,  and  the  ribs  are  so  close  together  that  it  is  difficult  to  get 
a  tube  into  the  chest,  and  when  inserted  it  is  liable  to  be  nipped  by  pressure 
of  the  ribs.  In  such  cases  the  ribs  should  be  prised  apart  with  dressing- 
forceps,  and  a  rigid  tube,  such  as  a  silver  or  vulcanite  tracheotomy  tube, 
employed,  or  a  piece  of  rib  should  be  excised,  which  is  a  far  better  plan. 
The  tube  should  not  project  far  into  the  pleural  cavity,  but  only  just  enough 
to  be  clear  of  the  thickened  pleura,  otherwise  it  will  fail  to  drain  the  cavity, 
and  may  be  blocked  by  pressure  against  the  lung.  A  double  tube,  or  two 
pieces  of  tubing  fixed  together  side  by  side  (Battams),  are  preferred  by  some 
surgeons  ;  the  plan  is  useful  if  it  is  intended  to  wash  out  the  chest,  but  in 
many  cases  it  is  open  to  the  objection  given  above. 

After  opening  the  chest  a  finger  should  be  passed  in  if  possible  to 
ascertain  the  size  of  the  cavity  and  to  break  down  any  adhesions  shutting  in 
localised  collections  of  pus,^  as  well  as  to  remove  any  masses  of  lymph  or 
solid  material  in  the  cavity.  If  the  pus  is  foul  or  thick  and  flaky,  as  large  a 
tube  as  possible  should  be  put  in,  and  all  solid  and  offensive  matter  care- 
fully removed  after  resection  of  a  portion  of  a  rib.  Should  any  bleeding 
occur  from  the  intercostal  vessels,  they  may  be  picked  up  or  secured  by  a 
catgut  ligature  passed  round  the  rib  including  the  vessel  ;  this  is  easily  done 
with  an  aneurism  needle.  Bleeding  from  the  granulating  surface  of  the  pleura 
after  exploration  soon  ceases  of  itself,  but  all  clots  should  be  washed  out. 

During  the  operation  careful  watch  must  be  kept  by  the  anaesthetist  that 
the  child  does  not  suffer  from  having  to  lie  upon  the  sound  side,  and  at  any 
sign  of  failing  pulse  or  respiration  the  child  must  be  turned  upon  its  back  or 
towai"ds  the  aftected  side.  The  after-treatment  of  empyema  consists  in 
keeping  the  cavity  aseptic  and  well-drained  ;  obstruction  of  the  tube  is  most 
likely  to  be  due  to  flakes  of  lymph  or  to  slipping  of  the  tube  if  a  rigid  one  is 
used,  to  nipping  of  the  tube  by  the  ribs  if  rubber  is  employed.  As  regards 
washing  out  the  chest  it  must  be  remembered  that  there  is  a  certain  amount 
of  danger  in  it ;  cases  of  sudden  death  during  the  process  have  several  times 
been  recorded,  possibly  from  irritation  of  cardiac  nerves  in  the  wall  of  the 
cavity,  or  from  sudden  dyspnoea  ;  this  risk  should  deter  us  from  washing 
out  an  empyema  unless  the  discharge  continues  to  be  foul,  and  it  should 
lead  to  caution  and  the  avoidance  of  any  distension  of  the  cavity  or  the  use 
of  irritant  lotions  even  in  such  cases.  In  free  incision  of  the  chest  the  opening 
is  of  course  large  enough  to  admit  air  readily,  hence  there  is  no  obstacle  to 
complete  emptying  of  the  cavity.  The  tube  should  not  be  left  out  until  the 
discharge  has  nearly  or  quite  ceased,  and  exploration  with  a  probe  has  shown 
that  the  cavity  is  filled  up  ;  often,  though  there  is  but  httle  discharge,  a  good- 
sized  ca.vity  or  a  long  sinus  remains,  and  if  the  external  wound  is  allowed  to 
close,  fresh  collections  of  pus  will  take  place.     In  a  certain  number  of  cases 

1  The  objection  that  an  empyema  usually  heals  up  at  the  back  first,  and  that  therefore 
a  cavity  is  likely  to  remain  unclosed  in  front,  has  not  in  our  experience  proved  a  valid 
objection  to  the  posterior  incision. 

-  Dr.  Fagge  states  that  loculation  is  very  rarely  found /cj/  mo7'tem. 


Empyema 


385 


the  empyema  will  be  pointing  externally  when  the  case  is  first  seen  ;  such 
pointing  most  commonly  occurs  in  the  front  of  the  chest  from  the  second  to 
the  fifth  space,  the  matter  sometimes  pushing  forward  and  pointing  through 
the  mamma.  If  the  skin  is  already  thinned  the  pus  should  be  let  out  at  this 
spot  and  the  case  managed  as  usual  ;  if,  however,  the  cavity  does  not  drain 
freely,  a  long  probe  should  be  passed  through  the  anterior  orifice,  and  cut 
down  upon  at  a  more  dependent  spot,  and  a  drainage  tube  inserted  there. 
While  admitting  that  the  successful  management  of  empyema  is  not  simply  a 
t|ucstion  of  drainage  as  in  other  abscesses,  we  think  a  dependent  opening  is 
a  highly  important  matter.     A  free  outlet  is  absolutely  essential. 

Sometimes  the  pressure  of 
the  drainage  tube  causes  ulcera- 
tion of  one  of  the  ribs  ;  this  is, 
however,  a  matter  of  little  im- 
portance, since  the  rib  usually 
recovers  after  removal  of  the 
tube. 

In  a  certain  proportion  of 
cases,  after  drainage  of  the  em- 
pyema, the  cavity  does  not 
become  obliterated,  but  remains 
as  a  pus- secreting  sac  ;  this  is 
due  either  to  imperfect  expan- 
sion of  the  lung  or  insufficient 
compensatory  falling  in  of  the 
chest  wall.  Under  such  con- 
ditions the  discharge  may  go 
on  indefinitely  and  cause  larda- 
ceous  disease  and  hectic  fever  ; 
it  is  then  necessary  to  find  other 
means  of  allowing  the  surfaces 
of  the  abscess  sac  to  come 
together.  For  this  purpose  re- 
section of  one  or  more  ribs  (Est- 
lander's  operation ')  has  been 
devised.  Although  in  children, 
from  the  softness  and  flexibility 
of  the  ribs  and  spine,  the  chest 
generally  falls  in  readily,  this  is 
by  no  means  always  the  case,  and  the  operation  should  be  done  as  soon  as  it 
is  clear  that  progress  is  not  being  made  or  the  child's  health  is  failing. 
Where  there  is  an  insufficient  opening  for  drainage,  it  is  also  necessary  in 
some  cases  to  provide  a  larger  orifice  by  removal  of  part  of  a  rib  ;  and, 
indeed,  it  is  a  good  practice  to  excise  a  portion  of  rib  in  all  cases  where  the 
child  is  not  so  feeble  as  to  make  even  this  slight  addition  to  the  severity  of 
the  operation  undesirable.  The  operation  is  a  simple  one  ;  to  remove  a 
single  rib,  the  lowest  one  in  the  cavity  should  be  chosen,  usually  the  seventh 

'  Estlander's  operation  is  strictly  the  removal  of  a  sufficient  part  of  the  chest  wall  to 
allow  of  complete  collapse. 

C  C 


Fig.  73. — Deformity  of  Chest  due  to  Empyema. 


386  Diseases  of  the  Respiratory  Apparatus 

or  eighth.  An  incision  is  made  along  it  down  to  the  bone,  the  periosteum  is 
readily  peeled  back  with  a  raspatory,  and  about  an  inch  or  more  of  the  rib  is 
cut  out  with  bone  forceps  ;  the  periosteum  and  pleura  are  then  incised 
parallel  with  and  avoiding  the  intercostal  vessels  ;  if  the  artery  is  wounded, 
however,  it  is  easily  secured  now  that  the  rib  is  gone.  When  the  resection 
is  done  to  allow  collapse  of  the  chest  wall,  from  two  to  five  ribs  may  have  to 
be  resected,  two  or  three  inches  of  bone  being  taken  from  each  ;  in  such 
case  a  quadrilateral  flap  of  the  soft  parts  should  be  turned  forward  and  the 
ribs  removed  one  after  the  other.  Though  it  is  perhaps  better  in  such  cases 
to  remove  the  bones  subperiosteally,  the  periosteum  should  be  cut  away 
before  closing  the  wound,  otherwise  it  often  happens  that  ossification 
rapidly  takes  place  and  fills  up  the  gap  in  the  chest  wall,  and  so  prevents  the 
desired  collapse.  We  have  sometimes  found  the  intercostal  vessels  ob- 
literated in  these  cases,  and  there  has  been  no  arterial  bleeding  at  all. 
Marshall  has  divided  the  costal  cartilages  subcutaneously  with  the  same 
object,  but  resection  is  the  more  complete  operation,  and  it  sounds  and 
looks  more  formidable  than  it  is.  The  subsequent  management  of  the 
wound  requires  no  description.  Unless  an  empyema  speedily  recovers, 
more  or  less  retraction  of  the  side  necessarily  results,  and  from  this  a 
lateral,  or  rather,  as  Lane  has  pointed  out,  a  true  rotato-lateral  curvature  of 
the  spine  follows  :  this  of  course  is  largely  irremediable,  but  some  improve- 
ment   may    be    obtained    by    treatment     {vide     Lateral    Curvature). 

(Fig.  12>-) 

Inasmuch  as  the  ribs  are  less  yielding  near  the  angles,  it  is  better  to 
remove  the  bone  as  far  back  as  possible  up  to  the  edge  of  the  erector  spinse. 
We  have  tried  osteotomy  of  the  rib  at  the  posterior  part  at  the  same  time  as 
resection  to  allow  more  complete  falling  in  of  the  chest  wall,  but  found  little 
was  to  be  gained  by  this  means,  since  the  rib  is  held  firmly  in  place  by  the 
surrounding  soft  parts. 

Spasmodic  Asthma 

Spasmodic  Asthma  is  a  disease  which  perhaps  ought  to  be  classed  with 
the  '  neuroses,'  but  on  account  of  its  frequent  association  with  bronchial 
catarrh  and  emphysema  it  is  most  convenient  to  discuss  it  under  respiratory 
diseases.  'Asthma'  or  a  condition  of  urgent  dyspnoea  occurs  in  renal 
disease,  cardiac  failure,  pressure  on  the  air-passages  by  tumours,  and  in 
hysteria  ;  but  in  these  instances  the  dyspnoea  is  secondary,  and  need  not  be 
discussed  here.  The  term  asthma  is  popularly  applied  to  chronic  bi'onchitis, 
but  it  is  needless  to  say  that  the  dyspnoea  of  bronchitis  is  caused  by  bronchial 
tubes  choked  by  thick  mucus,  and  not  by  spasm  of  the  bronchial  muscles,  as 
it  presumably  is  in  asthma. 

True  asthma  appears  to  be  related  to  '  cyclic  '  vomiting,  recurring  head- 
aches, and  epilepsy,  and  is  due  to  functional  disturbance  of  the  respiratory 
centre  brought  about  by  some  reflex  irritation.  It  is  a  common  disease  in 
children,  commencing  in  some  instances  in  the  second  or  third  year,  but 
perhaps  more  frequently  later.  In  some  respects  it  resembles  laryngismus, 
but  as  far  as  we  know  children  who  suffer  from  laryngismus  do  not  exhibit 
any  tendency  to  asthma.  The  disease  is  frequently  hereditary,  or  at  least 
runs  in  families. 


spasmodic  AstJiiiia  387 

The  exciting  causes  of  an  attack  are  various,  the  commonest  being  a 
bronchial  catarrh  or  bronchitis,  nasal  catarrh,  especially  where  there  are  also 
'  post  nasal  adenoids,'  'hay  fever,'  undigested  food  in  the  alimentary  canal. 
The  acute  attack  usually  begins  in  the  small  hours  of  the  morning,  the  child 
being  seized  with  dyspnoea  ;  it  sits  up  in  bed  and  fights  for  its  breath,  the 
respirations  are  quick,  the  alte  nasi  work,  and  the  face  is  a  dusky  colour  and 
the  lips  cyanosed.  On  listening  to  the  chest,  hissing  and  rhonchi  are  heard  all 
over.  The  attack  may  last  for  several  hours,  then  the  dyspnoea  becomes  less 
urgent  and  a  free  secretion  of  mucus  takes  place.  While  such  is  the  course 
of  a  typical  uncomplicated  attack,  we  constantly  find  there  is  more  or  less 
bronchitis  associated  with  it.  Before  the  attack  develops  there  is  for  some 
hours  or  days  a  certain  wheeziness  noted,  and  an  acute  exacerbation  occurs 
at  night  time  ;  next  day  there  is  no  distress,  but  rhonchus  can  be  heard  all 
over  the  chest,  and  any  exertion  causes  dyspncea.  The  child  is  a  long  time 
before  its  chest  is  normal,  and  then  perhaps  exposure  to  cold  brings  on  an- 
other bronchial  catarrh  and  another  attack  of  asthma.  As  time  goes  on  if 
the  attacks  follow  one  another  with  great  frequency,  the  lungs  become 
emphysematous  and  the  chest  constricted.  Asthma  is  not  dangerous  to  life, 
there  does  not  seem  to  be  any  special  tendency  to  tuberculosis  in  those  who 
suffer,  but  the  prognosis  as  far  as  the  attacks  are  concerned  is  uncertain. 

With  regard  to  the  treatment,  diet  is  of  a  great  importance,  as  there  can 
be  no  doubt  that  indigestion  aggravates  or  in  some  cases  starts  the  attacks. 
As  a  general  rule  the  child  should  live  largely  on  eggs,  vegetables  and  milk, 
using  meat  sparingly  ;  but  fish,  chicken  and  soup  may  be  allowed.  Alcohol 
and  all  highly  seasoned  foods  should  be  avoided.  Care  should  be  taken  with 
regard  to  the  clothing ;  it  is  especially  important  that  the  undergarments  should 
be  all  wool  so  as  to  avoid  chills.  There  must  be  no  'coddling '  at  one  time  and 
carelessness  as  regards  colds  at  another  time.  Plenty  of  fresh  air  whenever 
possible,  and  no  steamy,  over-heated  rooms  during  a  bronchial  attack. 
Climate  is  of  great  importance,  but  it  is  not  easy  to  say  what  climate  will  suit. 
Some  do  best  in  climates  like  Falmouth,  Sidmouth,  or  the  South  of  France, 
during  the  winter,  and  Buxton,  Malvern — in  summer — or  high  lands  which 
are  breezy  and  bracing.  Between  the  attacks  the  best  medicine  is  cod  liver  oil 
in  some  form  ;  both  arsenic  and  iodide  of  potassium  may  be  tried  and  are 
sometimes  of  benefit.  Carlsbad  salts  and  citrate  of  lithia  and  potash  are 
useful  in  aperient  doses  from  time  to  time.  During  the  attack  the  fumes  of 
burning  powder  containing  stramonium,  nitre  and  tobacco  unquestionably 
relieve  the  majority  of  cases.  The  drug  which  most  quickly  reheves  is 
morphia  subcutaneously,  yV  to  ^  of  a  grain  being  the  usual  dose  for  a  child 
of  seven  to  ten  years  of  age.     Chloral  is  useful  but  acts  more  slowly. 

Nasal  adenoids  and  hypertrophied  tonsils  should  be  removed,  as  they 
aggravate  the  attacks  by  obstructing  the  air  passages,  and  they  are  moveover 
a  source  of  discomfort  to  the  patient.  We  doubt  very  much  if  spasmodic 
asthma  is  ever  cured  by  their  removal,  but  the  general  health  and  comfort 
of  the  child  is  improved. 

Diseases  of  the  Bronchial  Glands 

The  tracheo-bronchial  glands  are  situated  in  the  middle  mediastinum 
in  close  relationship  with  the  trachea  and  bronchi  ;  they  are  some  ten  to 

c  c  2 


388  Diseases  of  the  Respiratory  Apparatus 

twelve  in  number,  and  are  arranged  in  three  groups  ;  one  set  surrounds  the 
trachea,  another  group  is  situated  at  the  bifurcation,  and  a  third  around  the 
right  and  left  bronchi.  The  pulmonary  glands  are  situated  at  the  root  of 
the  lung  and  accompany  the  bronchi  into  the  substance  of  the  lung.  These 
glands  receive  the  lymphatics  of  the  lungs  and  bronchi,  and  like  other 
lymphatic  glands  readily  become  inflamed  and  swollen  during  attacks  of 
bronchitis  and  broncho-pneumonia,  especially  after  measles  and  whooping 
cough,  and  are  apt  to  remain  chronically  enlarged,  and  further  to  become 
caseous  and  to  suppurate.  During  this  inflammatory  process  more  or 
less  thickening  and  matting  often  takes  place  in  surrounding  parts,  so  that 
the  glands  may  become  adherent  to  the  trachea  or  bronchi  or  oesophagus. 
The  glands  and  connective  tissue  in  the  anterior  and  posterior  mediastinum 
may  also  become  affected,  so  that  the  antero-internal  edges  of  the  lungs 
and  the  whole  contents  of  the  mediastinum  may  become  thickened  and 
matted  together. 

Caseation  of  the  mediastinal  glands  is  exceedingly  common  in  children, 
and  they  may  be  found  in  this  condition  in  the  bodies  of  children  dying  of 
various  diseases,  but  they  are  almost  universally  caseous  in  those  dying  of 
pulmonary  tuberculosis  or  chronic  catarrhal  pneumonia.  In  many  cases 
of  acute  or  chronic  tuberculosis  it  is  clear  that  the  disease  in  the  glands  is 
older  than  the  tubercle  in  the  lungs,  and  has  spread  from  the  former  to  the 
latter.  In  such  cases  the  glands  have  become  enlarged  secondarily  to  some 
bronchitis  or  pneumonia,  have  undergone  caseation,  and  the  lungs  have  been 
infected  in  consequence  of  caseating  bronchial  or  pulmonary  glands,  the 
tubercular  disease  spreading  into  the  lungs  from  the  root.  (See  TUBER- 
CULOSIS, p.  230.) 

Symptoms. — In  the  large  majority  of  cases  there  are  no  distinctive 
symptoms  of  caseating  mediastinal  glands,  and  per  se  they  are  not  more 
likely  to  give  rise  to  symptoms  than  caseating  glands  in  the  neck  ;  but,  inas- 
much as  they  are  so  frequently  associated  with  early  or  chronic  tuberculosis 
of  the  lungs,  the  subjects  of  them  are  hardly  likely  to  present  the  appearances 
of  health.  Not  infrequently,  however,  they  are  found  unexpectedly  in  the 
bodies  of  children  dying  of  other  diseases.  With  regard  to  physical  signs,  it 
must  be  clear  from  a  consideration  of  the  anatomy  of  the  mediastinum  that 
the  glands  lie  too  deeply  to  be  detected  by  percussion  unless  they  are 
enormously  enlarged  ;  this  may  take  place  in  sarcomatous  enlargement,  but 
rarely  in  tuberculosis.  It  has  been  asserted  that  when  enlarged  they  can  be 
detected  by  a  diminished  resonance  in  the  interscapular  region,  correspond- 
ing to  the  first  three  dorsal  vertebrae  ;  but,  inasmuch  as  the  thick  posterior 
edges  of  the  lungs,  besides  the  aorta,  cesophagus,  and  a  mass  of  muscle, 
intervene  between  the  glands  and  the  surface,  it  is  certain  that  the  enlarge- 
ment must  be  very  considerable  to  modify  the  percussion  note  in  this 
position.  Enlarged  glands  are  more  likely  to  modify  the  resonance  behind 
the  upper  part  of  the  sternum  and  adjacent  cartilages,  but  in  infants  and 
young  children  the  anterior  mediastinum  is  occupied  by  the  thymus,  which 
would  mask  any  enlargement  of  the  lymphatic  glands  ;  and  in  older 
children,  where  the  thymus  is  small,  lymphatic  glands  must  be  very  much 
enlarged  to  come  to  the  surface  and  give  rise  to  any  dulness,  covered  as 
they  are  by  the  anterior  edges  of  the  lungs.     Error  may  easily  arise  from  a 


Diseases  of  the  Bronchial  Glands 


389 


dulness  due  to  a  past  pleurisy  and  consequent  adhesion  along  the  anterior 
edges  of  the  lungs.  If  the  results  of  percussion  are  uncertain,  those  derived 
from  auscultation  are  necessarily  more  so,  except  in  considerable  enlarge- 
ment of  glands.  Of  the  pressure  signs,  the  most  reliable  is  weak  breathing 
in  one  of  the  lungs  in  consequence  of  pressure  on  the  right  or  left  bronchus  ; 
this  sign  is  of  undoubted  value,  but  as  there  is  usually  some  tubercular  lesion 
in  the  lungs,  this  symptom  may  readily  be  masked.  Attacks  of  paroxysmal 
dyspnoea,  and  cough  with  stridulous  breathing,  may  also  be  present  on 
account  of  the  nerves  being  involved.  Swelling  of  the  face  and  dis- 
tension of  the  jugulars  have  also  been  described,  but  these  are  far  more 


Fig.  74.— Section  through  a  large  mass  of  cheesy  glands  at  the  bifurcation  of  the  trachea,  and 
extending  along  the  bronchi  into  the  lung.  Two  of  the  glands  are  beginning  to  show  signs 
of  softening  at  their  centres.     (After  W.  P.  Northrup,  M.D.) 

frequently  due  to  constant  coughing  than  to  any  pressure  on  the  large  veins 
in  the  chest.  A  caseous  gland  not  infrequently  becomes  adherent  to  the 
trachea  or  one  of  the  bronchi,  and  ulcerates  into  it,  and  caseous  matter  may 
be  coughed  up  ;  in  a  few  instances  it  has  happened  that  this  takes  place 
suddenly  and  death  results  from  plugging  of  the  windpipe.  In  other 
instances  the  glands  may  form  an  abscess  which  points  in  one  of  the  inter- 
costal spaces  close  to  the  sternum,  as  in  a  case  under  the  care  of  Dr. 
Eustace  Smith,  or  may  open  into  the  oesophagus.  In  one  of  our  own  cases  a 
mediastinal  abscess  pointed  near  the  left  edge  of  the  sternum,  low  down. 


390  Diseases  of  the  Respiratory  Apparatus 

The  pulmonary  glands  which  accompany  the  small  bronchial  glands  into 
the  lungs  may  become  caseous,  soften,  and  form  cavities,  more  especially  in 
the  lower  lobes.  It  must  be  acknowledged  that  caseous  glands  can  rarely 
be  diagnosed  during  life  with  anything  like  certainty,  partly  on  account  of 
their  lying  deeply,  and  partly  from  the  fact  that  they  are  so  commonly  asso- 
ciated with  chronic  lung  disease.  They  rarely  attain  any  large  size,  and 
consequently  do  not  modify  the  percussion  note  or  press  on  the  veins,  bronchi, 
or  nerves. 

When,  however,  the  mediastinal  glands  become  the  seat  of  a  new  growth, 
such  as  lyiuphadenoma,  the  case  is  different ;  they  may  become  enormously 
enlarged,  surrounding  the  veins  and  bronchi,  giving  rise  to  marked  dulness 
over  the  sternum  and  adjoining  rib  cartilages,  and  pressure  signs  from 
involving  the  vessels.  Attacks  of  paroxysmal  breathing  are  common  on 
account  of  pressure  on  the  recurrent  laryngeal  and  other  nerves.  The  course 
of  the  disease  usually  extends  over  a  few  months  only,  the  patient  getting 
progTessively  worse.  Among  the  early  symptoms  will  usually  be  those  of 
disturbed  innervation.  There  are  attacks  of  paroxysmal  cough,  with  a  metal- 
lic ring  and  stridulous  breathing  and  orthopnoea,  so  that  the  child  has  to 
be  propped  up  to  get  its  breath  ;  in  the  later  stages  the  distress  is  often  very 
great.  The  voice  is  altered,  perhaps  reduced  to  a  whisper.  The  return  of 
blood  to  the  chest  may  be  interfered  with  on  account  of  the  superior  vena 
cava  being  compressed,  giving  rise  to  a  distension  of  the  jugular  or  axillary 
veins  and  swelling  of  the  face  or  arms.  Fluid  may  be  present  in  one  or  both 
pleural  cavities  from  pressure  on  the  azygos  veins.  If  the  tumour  is  of  any 
size,  there  will  be  dulness  over  the  sternum  or  in  the  adjoining  region,  parti- 
cularly to  the  left  edge  of  the  sternum  in  the  upper  intercostal  spaces.  In- 
tense bronchial  breathing  may  be  heard  here.  Moreover,  the  lung  may  be 
pushed  to  the  left  by  the  encroachment  of  the  tumour,  which  may  bulge 
forward  the  sternum  and  ribs. 

Chronic  Tuberculosis    of  the  Ibung's 

Infancy  and  Early  CJiildhood. — No  age  is  free  from  liability  to  be  affected 
with  tubercle  ;  thus  Demme  has  found  tubercular  disease  of  the  intestine  in 
an  infant  of  twenty-nine  days. 

Tubercular  disease  is  not  common  in  infants  of  a  few  months  old  ;  at 
this  period  gastro-intestinal  atrophy  is  exceedingly  common,  and  is  liable 
to  be  mistaken  for  tubercular  disease  on  account  of  the  wasting  which  takes 
place.  Tuberculosis  in  young  children  rarely  begins  as  does  the  phthisis  of 
adults  by  a  growth  of  tubercle  and  a  condensation  at  the  apices  of  the  lungs, 
and  a  gradual  extension  downwards  taking  place,  but  is  apt  to  be  far  more 
widespread  in  its  distribution  both  in  the  lungs  and  in  the  body.  It  is  there- 
fore far  more  difficult  to  diagnose  by  means  of  physical  signs  which  are  less 
distinctive  than  are  those  of  adults.  It  is  needless  to  say  that  the  same 
general  appearances  are  found  in  the  bodies  of  children  as  in  adults  dying  of 
tuberculosis — grey  tubercle,  caseous  masses,  iron-grey  infiltration  and  fibroid 
tissue  in  excessive  quantity,  and  irregular  cavities.  The  distribution,  however, 
usually  differs,  one  of  the  chief  differences  being  that  in  adults  the  tubercular 
processes  appear  to  have  a  special  affinity  for  the  apices  ;  in  early  childhood 


Tuberculosis  of  the  Lungs  391 

there  is  no  such  predilection,  the  hilus  of  the  lung  or  base  being-  frec[uently 
affected  before  the  apex.  The  bronchial  glands  are  almost  constantly 
found  caseous,  with  also  the  small  pulmonary  glands  which  accompany  the 
bronchi,  the  latter  suppurating  and  forming  small  cavities  near  the  root  of 
the  lungs.  In  this  way  a  tuberculosis  may  spread  into  the  lungs  from  the 
hilus.  Not  infrequently  one  or  both  bases  are  semi-solid  from  caseating 
pneumonia  with  ragged  cavities,  at  other  times  a  similar  state  of  things  is 
found  at  the  apex.  In  other  cases  both  lungs  are  stuffed  with  clusters  of 
grey  or  yellow  tubercles  surrounding  the  terminal  bronchi.  There  may  be 
tubercle  on  the  surface  of  the  pleura,  with  more  or  less  pleurisy  or  small 
local  empyemas.  The  abdominal  organs  are  exceedingly  apt  to  be  affected  : 
cheesy  masses  are  frecjuently  found  in  the  liver,  spleen  and  kidneys  ;  cheesy 
mesenteric  glands  and  ulceration  of  the  intestines  are  very  common  in  cases 
of  general  tuberculosis.  Tubercles  are  not  infrequently  found  on  the  peri- 
toneum and  other  serous  membranes,  as  the  pleura  and  meninges  of  the 
brain.  Tubercular  disease  of  bone  may  be  associated  with  a  general  dis- 
tribution of  tubercle  throughout  the  body.     (See  Tuberculosis,  p.  230.) 

Syviptoms. — If  the  diagnosis  of  phthisis  in  the  early  stages  is  difficult  in 
adults,  when  it  is  possible  to  carefully  auscultate  and  percuss  the  apices 
of  the  lungs,  examine  the  sputa  for  bacilli,  and  cross-question  the  patient 
concerning  the  symptoms  presented,  it  is  necessarily  much  more  difficult  in 
the  infant  or  young  child,  where  the  symptoms  are  rarely  definite  and  where 
the  lesions  are  so  widely  spread  throughout  the  body.  The  younger  the 
subject  the  more  likely  are  the  symptoms  to  be  wanting  in  distinctiveness 
and  the  diagnosis  to  be  consequently  difficult,  frequently  wasting  and  a 
family  history  of  tuberculosis  being  nearly  all  there  is  to  go  by.  The  tem- 
perature is  usually  hectic,  normal,  or  perhaps  subnormal  in  the  morning,  and 
reaching  102°  or  103°  in  the  evening,  though  this  may  be  reversed.  There 
may  be  diarrhoea  without  apparent  cause,  and  various  dyspeptic  troubles  ; 
cough,  though  this  may  be  absent  ;  perhaps  enlargement  of  some  external 
glands.  An  examination  of  the  lungs  may  reveal  very  little,  perhaps  some 
want  of  resonance  over  the  base  or  apex  or  in  the  interscapular  region  or 
axilla,  with  some  ringing  consonant  rales  or  crepitation.  There  is  progressive 
wasting,  which  in  a  child  of  over  a  year  or  eighteen  months  is  more  sus- 
picious than  in  an  infant  a  few  months  old,  where  wasting  is  more  often 
due  to  chronic  intestinal  catarrh  than  to  tuberculosis.  In  those  cases  where 
wasting  and  hectic  follow  measles,  whooping  cough,  bronchitis,  or  broncho- 
pneumonia, thei-e  is  a  strong  suspicion  of  tuberculosis,  even  though  there 
may  have  been  a  period  of  comparative  health  intervening  between  the 
acute  attack  and  the  hectic  supervening  ;  a  family  history  of  phthisis  would 
make  the  case  look  still  more  threatening.  In  the  later  stages  the  sym- 
ptoms become  more  decisive.  The  hectic  continues,  the  wasting  is  pro- 
gressive, the  cough  is  troublesome,  the  diarrhoea  perhaps  is  still  present, 
parasitic  stomatitis  makes  its  appearance,  the  feet,  hands,  and  face  become 
oedematous,  and  the  child  is  anaemic  and  very  weak.  Examination  of 
the  chest  will  now  show  some  marked  dulness  or  loss  of  resonance  over 
some  portion  of  lung,  apex  or  base,  with  bronchial  breathing  and  sharp  con- 
sonating  riles  ;  often  one  is  surprised  to  find  how  little  can  be  detected 
in  the  chest,  even  when  it  is  evident  that   the   child   is   far   advanced   in 


392  Diseases  of  the  Respiratory  Apparatus 

tubercular  disease.  The  typical  signs  of  a  cavity  can  rarely  be  elicited, 
inasmuch  as  the  cavities  in  the  lungs  of  infants  and  young  children  are  not 
often  larger  than  marbles  or  walnuts  ;  most  frequently  they  have  irregular 
and  ragged  walls.  A  cracked-pot  sound  may  sometimes  be  elicited  in  front, 
but  on  account  of  the  yielding  nature  of  the  chest  walls  in  an  infant  it  is 
of  no  diagnostic  value  as  regards  a  cavity. 

Diagnosis. — Whenever  wasting  occurs  as  a  prominent  symptom  during 
infancy  and  childhood,  tuberculosis  is  certain  to  be  thought  of;  wasting 
occurs  in  all  dyspeptic  diseases  during  infancy,  and  it  may  simulate  the 
wasting  of  tuberculosis  when  it  occurs  in  connection  with  empyema  or 
broncho-pneumonia  in  young  children.  An  empyema  may  readily  be  mis- 
taken for  tuberculosis  of  the  lung  if  a  careful  examination  of  the  lungs  is 
not  made,  aided  if  necessary  by  an  exploratory  puncture,  as  there  is  wasting, 
hectic,  and  cough.  The  difficulty  in  deciding  may  be  great  without  explora- 
tion if  the  empyema  is  localised  or  there  is  more  than  one.  A  chronic 
effusion  in  the  pericardium  may  be  mistaken  for  tubercular  disease.  It  is 
often  difficult  in  cases  of  chronic  broncho-pneumonia,  the  chronic  condition 
following  an  acute  attack,  to  decide  if  a  tubercular  process  is  going  on. 
There  may  be  wasting  and  hectic,  and  yet  after  some  weeks  the  temperature 
will  gradually  fall,  the  lung  clear  up,  and  the  child  perfectly  recover.  In 
most  cases  only  the  progress  of  the  case  will  decide  the  question. 

Older  Children. — After  the  age  of  six  years — in  other  words,  after  the 
commencement  of  the  second  dentition — chronic  tuberculosis  much  more 
frequently  resembles  the  chronic  phthisis  of  adults  than  it  does  before  this 
era.  As  the  child  gets  older  the  resemblance  becomes  still  more  close. 
Children  before  this  age  rarely  suffer  from  chronic  tuberculosis  of  the  adulttype. 
The  early  symptoms  are  those  of  cough,  loss  of  appetite,  diarrhoea,  wasting, 
night  sweats,  and  hectic  ;  progressive  weakness  ;  the  symptom  which  we  miss 
for  the  most  part  is  hemoptysis,  which,  though  sometimes  present,  is  much 
more  frequently  absent  in  children  than  in  adults,  and  less  blood  is  expectorated. 
An  examination  of  the  chest  may  perhaps  disclose  some  loss  of  resonance  at 
one  apex  (usually  the  right),  with  perhaps  some  rhonchus  or  moist  sounds, 
or  there  may  be  no  loss  of  resonance,  only  the  signs  of  a  chronic  or  subacute 
bronchial  catarrh  localised  in  the  apex  of  a  lung  ;  or  there  may  be  impaired 
resonance  only,  due  to  the  presence  of  a  thickened  pleura  and  adherent 
lung.  In  this  stage  children  perhaps  more  often  than  adults  improve  under 
treatment  and  a  careful  hygiene,  and  may  be  restored  to  perfect  health  ;  there 
is  abundant  evidence  to  demonstrate  this.  If  the  disease  progresses  the 
hectic  and  wasting  continue,  the  child  becomes  pallid  and  weak,  the  diar- 
rhoea frequent  and  troublesome,  especially  following  meals  ;  the  physical 
signs  show  an  extended  area  of  lung  involved,  the  tubercular  infiltration 
travelling  from  the  apex  towards  the  base,  and  giving  rise  to  caseous  degene- 
ration, fibroid  changes,  and  cavitation.  The  progress  of  such  cases  is  apt 
to  be  more  rapid  than  it  is  in  adults,  a  fatal  result  occurring  in  four  to 
six  months.  In  the  last  stages  the  emaciation  is  extreme,  the  feet  oedematous, 
bed  sores  are  apt  to  form,  and  while  the  patient  may  linger  for  a  while  if  no 
intercurrent  affection  brings  the  end  quickly,  it  must  be  borne  in  mind  that 
such  cases  are  exceedingly  apt  to  be  brought  to  a  conclusion  by  tubercular 
meningitis  in  any  stage  early  or  late.     The  abdominal  organs  are  also  apt  to 


Tuberculosis  of  the  Liings  393 

join  in  a  more  extensive  spreading  of  tubercle  than  is  the  case  later  in  life  ; 
mesenteric  disease,  extensive  ulceration  of  bowels,  peritonitis  subacute 
or  acute,  are  apt  to  be  present,  and  necessarily  influence  the  course  of  the 
disease.  Haemoptysis,  which  may  be  fatal  almost  immediately,  occa- 
sionally occurs  ;  in  other  cases  blood  may  be  expectorated  in  considerable 
quantities. 

Sometimes  an  acute  phthisis  takes  place  without  miliary  tuberculosis 
being  present  ;  the  tubercular  process  taking  the  form  of  clusters  of  grey 
tubercle  surrounding  the  bronchi,  the  process  beginning  at  the  apex  and 
travelling  towards  the  base,  the  symptoms  being  those  of  a  rapid  phthisis, 
perhaps  extending  over  a  month  or  two. 

On  the  other  hand,  a  fibroid  phthisis  essentially  chronic  in  its  course 
may  take  place,  appearing  at  times  to  be  stationary,  or  the  patient  undergoes 
considerable  improvement.  In  these  cases  there  is  much  fibroid  change  and 
iron-grey  induration  of  lung  with  retraction  of  chest.  The  physical  signs 
develop  slowly,  there  is  dulness  of  an  apex,  which  gradually  becomes  almost 
absolute,  intense  bronchial  breathing,  consonant  rales  and  gradual  retraction 
of  the  affected  side.  The  child  may  fatten  and  appear  to  flourish,  and  present 
a  normal  temperature,  but  it  is  easily  exhausted,  suffers  from  dyspnoea  on 
exertion,  its  face  and  lips  are  turgid,  and  the  fingers  become  clubbed.  In 
a  few  cases  there  is  haemoptysis,  but  this  is  the  exception.  It  is  possible 
that  the  process  may  become  arrested,  the  lung  being  converted  into  fibroid 
tissue.  In  the  majority  of  cases  the  disease  is  progressive,  and  the  opposite 
apex  becomes  affected.  The  whole  course  may  extend  over  several  years, 
unless  bronchitis  or  some  other  intercurrent  disease  supervenes. 

The  principal  clinical  differences  between  chronic  phthisis  in  older  chil- 
dren and  adults  may  be  summed  up  as  follows  : 

1.  Frequency  with  which  children  in  the  first  stage  recover. 

2.  Frequency  with  which  the  disease  is  brought  to  an  abrupt  termination 
by  some  acute  affection,  as  tubercular  meningitis,  pleurisy,  peritonitis,  or 
acute  miliary  tuberculosis. 

3.  Comparative  rarity  of  haemoptysis  in  the  early  stages  and  of  laryngitis 
in  the  latter  stages. 

4.  Frequency  of  complication  with  abdominal  tuberculosis. 

5.  Comparative  rarity  as  compared  with  that  of  adults  of  extensive  cavities 
in  the  lungs. 

6.  Rarity  with  which  the  larynx  is  affected  with  tuberculosis. 

The  post-mortem  appearances  are  mostly  similar  to  those  found  under 
similar  circumstances  in  adults.  Irregular  ragged  cavities,  varying  in  size 
from  a  hazel  nut  to  a  walnut,  most  numerous  in  the  upper  lobes,  with  cheesy 
masses  and  fibroid  indurations  ;  the  same  condition  in  the  lower  lobes  in 
an  earlier  stage,  with  more  or  less  crepitant  lung.  As  a  rule  there  is  not 
much  grey  tubercle,  but  caseous  masses,  sometimes  associated  with  peri- 
bronchial grey  or  yellow  tubercles.  There  are  not  often  cavities  of  large 
size,  but  these  occur  at  times  ;  in  one  case,  in  a  boy  of  eight  years,  who  had 
suffered  for  six  months,  there  was  a  cavity  in  the  upper  two-thirds  of  the  left 
lung  as  large  as  an  adult's  clenched  fist.  Pleurisy  and  small  collections  of 
pus  are  not  uncommon.  The  bronchial  glands  are  almost  invariably  en- 
larged and  caseous. 


394  Diseases  of  the  Respii^atory  Apparatus 

Instead  of  the  above,  especially  in  the  more  acute  cases,  the  lungs  ma}' 
be  everywhere  infiltrated  with  clusters  of  peribronchial  tubercles,  which 
crowd  the  upper  lobes,  where  ragged  irregular  cavitation  is  commencing, 
while  they  are  more  sparely  scattered  thi-ough  the  lower  lobes. 

In  fibroid  phthisis  an  extensive  portion  of  one  or  both  lungs  is  cicatrised 
and  solid,  bands  of  fibrous  tissue  run  across,  there  is  much  grey  infiltration, 
dilated  bronchi,  caseous  glands,  and  perhaps  small  ragged  cavities.  Other 
portions  of  lung  are  hypertrophic  or  emphysematous,  perhaps  containing 
scattered  clusters  of  peribronchial  tubercles. 

Cheesy  tubercles  are  met  with  constantly  in  other  organs  than  the  lung, 
especially  in  the  liver,  spleen,  and  kidneys  ;  caseous  mesenteric  glands  and 
ulceration  of  the  intestines  may  also  be  associated  with  lung  mischief. 

Treatment. — The  treatment  of  enlarged  and  caseous  glands  is  necessarily 
the  same  in  large  measure  as  that  of  early  tuberculosis.  If  a  child,  say  one 
from  three  to  six  years  of  age,  suffers  from  a  hacking  paroxysmal  cough,  is 
slightly  feverish  at  night,  remains  in  a  condition  of  ill-defined  malaise,  especi- 
ally if  he  has  recently  suffered  from  bronchitis,  whooping  cough,  or  measles, 
the  suspicion  will  be  raised  that  there  is  either  caseation  of  the  bronchial  glands 
or  an  early  tuberculosis  of  the  lungs.  There  can  be  no  certainty  about  the 
diagnosis,  but  if  the  family  history  points  to  tuberculosis  there  is  only  too 
much  reason  for  anxiety.  The  indications  for  treatment  which  suggest 
themselves  are  to  place  the  child  under  conditions  in  which  there  will  be  the 
least  possible  irritation  of  the  lungs  and  bronchial  tubes,  and  to  supply  him 
with  nourishment  in  suitable  quantities  and  in  the  most  digestible  forms. 
It  is  needless  to  say  that  these  indications  are  fulfilled  with  difficulty  or  only 
partially.  Residence  in  the  smoke  and  dirt  of  large  towns,  or  on  damp 
clay  subsoils,  is  alike  bad,  and  if  possible  the  child  should  be  removed  to 
some  breezy  moorland  site  or  bracing  seaside  place.  Fresh  air  when  it  can 
be  taken  without  risk  of  cold  is  of  the  greatest  possible  advantag'e  in  bracing 
up  the  digestive  organs.  In  winter,  if  it  be  impossible  to  seek  a  warmer 
climate,  thoroughly  warm  and  well-ventilated  apartments  free  from  draughts 
must  be  secured.  A  well-warmed  but  not  '  stuffy '  house  is  a  great  advan- 
tage, as  the  child  may  in  such  a  case  have  the  '  run '  of  the  whole  house 
without  being  exposed  to  cold  passages  and  open  windows.  A  nourishing, 
easily  assimilated  diet  should  be  prescribed,  a  variety  being  introduced  in 
order  to  tempt  the  capricious  appetite  often  present.  A  cup  of  beef  tea 
the  last  thing  at  night  will  often  ease  the  cough  and  soothe  the  child  to  sleep. 

Of  special  medicinal  treatment,  cod  liver  oil,  malt  extract,  mineral  acids 
with  cinchonine  and  the  hypophosphites  may  be  prescribed  with  advantage. 
Creasote  or  guaiacol  is  often  prescribed.  Counter-irritants  are  useful  ;  they 
are  hardly  likely  to  have  much  effect  on  glands  which  are  actually  caseating, 
but  they  undoubtedly  favourably  influence  chronic  catarrhs  of  the  bronchial 
mucous  membranes.  Among  the  milder  ones,  the  lin.  pot.  iodid.  c.  sapone 
may  be  rubbed  into  the  chest  every  evening,  a  piece  of  '  swansdown  '  or  layer 
of  cotton  wool  being  applied.  A  stronger  application  may  be  made  by  diluting 
lin.  iodi  with  glycerine  and  water  (F.  27),  and  applying  it  to  the  sternum 
or  the  subclavicular  region  every  night  and  covering  it  over  with  a  layer  of 
cotton  wool.  Care  must  be  taken  not  to  render  the  skin  sore  by  applying  it 
too  frequently  on  the  same  spot. 


Tuberculosis  of  the  Lungs  395 

The  more  urgent  symptoms  present  when  the  nerves  arc  involved  by  a 
mediastinal  tumour — and  these  are  often  very  distressing — may  b§  relieved  in 
many  cases  by  warm  applications,  such  as  fomentations,  and  small  doses  of 
nepenthe  or  morphia.  Relief  will  probably  be  obtained  from  opiates  com- 
bined with  ether  or  chloroform  if  the  dyspnoea  is  due  to  spasm.  Inhalations 
of  chloroform,  ether,  or  nitrite  of  amyl,  usually  relieve.  Small  doses  of 
morphia  given  subcutaneously  may  be  tried. 

Much  that  has  been  said  applies  to  the  early  stages  of  all  forms  of  chronic 
tuberculosis  of  the  lungs.  It  is  of  the  greatest  possible  importance  to  recog- 
nise the  disease  in  its  early  stages,  when  there  is  a  fair  probability  that  it  may 
be  arrested  or  undergo  a  natural  cure  if  the  conditions  are  favourable.  To 
this  end  an  equable  temperature,  a  pure  bracing  air,  protection  from  cold  and 
damp  and  rapid  temperature  changes  are  of  the  greatest  importance.  The 
presence  of  tubercle  in  the  lungs  naturally  predisposes  to  catarrhs  and  local 
pneumonias,  and  exposure  to  unfavourable  conditions  likely  to  favour  their 
development  is  certain  greatly  to  aggravate  the  disease.  Great  care  must 
also  be  taken  in  the  food  which  the  child  takes  and  in  treating  any  departure 
from  a  healthy  condition  of  the  child's  digestive  system.  A  condition  of 
catarrh  of  the  bowels  is  very  often  present  in  tubercular  diseases  apart  from 
any  local  lesion,  and  is  an  impoitant  factor  in  producing  the  wasting  which 
accompanies  tuberculosis. 


396  Diseases  of  the  Circulatory  System 


CHAPTER   XVIII 

DISEASES    OF    THE   CIRCULATORY    SYSTEM 

Diseases  of  the  Heart 

Physical  Examination. — An  examination  of  the  heart  includes  an  en- 
deavour to  determine  its  position,  size,  and  the  character  of  the  cardiac 
sounds.  It  is  needless  to  say  that  the  younger  the  child,  the  more  difificult 
it  is  to  make  a  satisfactory  examination.  The  first  point  to  determine  is  the 
position  of  the  apex  beat,  and  as  this  gives  us  important  information  for 
making  a  diagnosis,  it  should  never  be  neglected.  If  not  visible  its  position 
may  usually  be  felt  by  laying  the  extended  hand  on  the  cardiac  area,  and 
note  must  be  made  as  to  whether  it  occupies  a  larger  space  than  normal,  and 
whether  it  is  accompanied  by  a  thrill.  The  usual  position  of  the  cardiac 
impulse  in  adults  is  in  the  fifth  interspace  and  well  within  the  left  nipple  line. 
Symington  has  shown,  by  a  number  of  frozen  sections  of  the  thorax  at  dif- 
ferent ages,  that  during  childhood  the  apex  beat  is  apt  to  take  a  more 
external  position  as  regards  the  nipple  than  in  later  years,  a  result  due  to 
the-  greater  relative  narrowness  of  the  child's  chest  in  the  transverse 
diameter.  As  a  matter  of  fact,  it  is  usually  well  within  the  nipple  in  most 
children  according  to  our  observations,  but  we  must  not  hastily  come  to  the 
conclusion  that  because  we  may  find  in  a  given  case  it  is  actually  in  a  line 
with  the  nipple  that  disease  is  present.  If  external  in  position  to  the  nipple 
we  should  always  be  suspicious  that  there  is  an  abnormal  displacement  of 
the  heart  to  the  left,  or  there  is  some  dilatation  of  the  left  ventricle.^  If  the 
impulse  is  raised  it  would  suggest  that  it  was  displaced  upwards  by  a  dis- 
tended stomach  or  other  abdominal  enlargement,  or  there  is  chronic  lung 
disease  of  the  left  apex,  or  possibly  pericardial  effusion.  If  the  impulse  is 
displaced  to  the  right  there  is  in  all  probability  fluid  in  the  left  pleura. 
Epigastric  pulsation  in  a  case  of  chronic  heart  disease  generally  means 
dilatation  of  the  right  ventricle.  A  heaving  impulse  lower  than  normal,  the 
chest  wall  being  lifted  during  systole,  suggests  hypertrophy  of  the  left 
ventricle,  a  diffused  weak  impulse  implies  dilatation. 

In  mapping  out  the  size  and  position  of  the  heart  by  means  of  percussion 
we  necessarily  take  the  '  deep  dulness '  as  our  guide,  but  as  the  cardiac 
dulness  shades  away  laterally  into  the  pulmonary  resonance,  great  care 
must  be  taken  in  the  determination.  Let  us  bear  in  mind  that  the  shape 
and  elasticity  of  the  chest  walls  may  modify  the  percussion  note,  and  this  is 

1  Steffen  comes  to  the  conclusion  that  in  most  children  the  cardiac  impulse  is  in  the 
nipple  line,  and  in  some  instances  one  cm.  external,  without  indicating  disease. 


Diseases  of  the  Heart — Congenital  Heart  Disease       397 

especially  true  in  percussing  over  the  lower  half  of  the  sternum.  Some  writers 
have  laid  down  rules  as  to  the  limits  of  the  cardiac  dulness  in  children  of 
\arious  ages.  We  doubt  very  much  the  correctness  of  some  of  the  statements 
which  have  been  made,  and  we  should  recommend  the  student  to  bear  in 
mind  only  the  limits  which  he  has  been  accustomed  to  observe  in  the  wards 
of  an  adult  hospital,  but  not  forgetting  that  an  extension  of  dulness  to  the  left 
more  than  in  the  case  of  adults  does  not  necessarily  mean  a  pathological  con- 
dition. The  upper  limit  of  the  heart  is  the  upper  edge  of  the  third  left  costal 
cartilage ;  dulness  extending  higher  than  this  suggests  fluid  in  the  pericar- 
dium, an  enlarged  heart,  or  a  lesion  at  the  left  apex  of  the  lung.  The  left 
border  of  the  heart  should  lie  within  a  curved  line  drawn  from  the  junction 
of  the  third  left  costal  cartilage  with  the  sternum,  extending  downwards  and 
to  the  left  to  the  fifth  space  just  within  the  nipple  line.  The  right  border 
corresponding  to  the  right  auricle  should  lie  within  a  line  drawn  from  the 
above  point  curving  downwards  and  outwards  along  the  right  edge  of  the 
sternum.  Inferiorly  the  cardiac  dulness  cannot  be  distinguished  from  the 
hepatic  dulness.  In  chronic  disease  the  chest  wall  is  frequently  bulged 
over  the  cardiac  area,  while  the  dull  area  is  extended  both  to  the  left  and 
right,  and  may  even  measure  as  much  as  6  inches  across  from  side  to  side. 
We  will  defer  reference  to  the  cardiac  sounds  till  later. 


Congenital  Heart  Disease 

The  different  forms  of  malformed  hearts  are  exceedingly  numerous  and 
defy  any  attempt  at  classification,  but  as  many  of  these,  though  of  great 
interest  to  the  anatomist  as  illustrating"  the  various  stages  of  development, 
are  of  little  practical  importance  to  the  clinician,  no  detailed  description  is 
needed  here.  The  principal  causes  at  work  in  producing  these  malformations 
may  be  classified  as  follows  :  (i)  Persistence  of  foetal  openings,  more  par- 
ticularly the  foramen  ovale,  in  consequence  of  the  lungs  remaining  in  part  in 
the  fcetal  state  after  birth  ;  there  is  obstruction  through  the  lungs  and  over- 
filling of  the  right  heart.  (2)  Endocarditis,  occurring  during  fcetal  life, 
affecting  the  pulmonary,  the  tricuspid,  and  less  often  the  aortic  or  mitral 
valves,  producing  stenosis  at  the  valvular  orifice,  and  as  a  secondary  effect 
the  persistence  of  the  foramen  ovale,  or  ductus  arteriosus  ;  or  the  septum 
ventriculorum  may  remain  incomplete.  (3)  An  arrest  of  development  at 
some  period  of  foetal  life  or  the  results  of  a  false  step,  as  it  were,  as  when 
a  transposition  of  the  aorta  and  pulmonary  artery  occurs. 

Congenital  heart  disease  not  infrequently  occurs  in  several  members  of 
the  same  family  ;  in  one  case  coming  under  our  notice,  where  there  were  four 
children  two  sisters  and  one  brother  were  thus  affected. 

Symptoms. — Cyanosis  and  the  presence  of  a  bruit  are  the  only  reliable 
signs  of  congenital  heart  disease.  Cyanosis  is  mostly,  but  not  universally, 
present,  and  it  varies  considerably  in  intensity.  It  is  most  marked,  and  is 
sometimes  only  present  when  the  infant  cries,  the  face  being  dusky,  the  lips 
and  tongue  and  extremities  becoming  of  a  bluish  tinge.  We  must,  however, 
bear  in  mind  that  some  cyanosis  may  be  present  in  prematurely  born  infants 
when  the  lungs  are  but  partially  inflated,  and  remain  in  the  foetal  state,  and 
often  atrophic  and  feeble  infants  have  blue  and  cold  hands  and  feet.     If, 


398  Diseases  of  the  Circulatory  System 

however,  the  cyanosis  persists  for  many  weeks,  it  is  probably  due  to  mal- 
formation of  the  heart.  In  a  certain  pi-oportion  of  cases  murmurs  are  heard. 
These  are  apt  to  be  of  a  rough,  rasping,  superficial  character,  and  the  rhythm 
is  often  exceedingly  difficult  to  determine,  on  account  of  the  rapid  action  of 
the  infant's  heart.  The  differential  diagnosis  is  very  frequently  impossible, 
and  only  a  sort  of  guess  can  be  made.  The  position  of  greatest  intensity 
should  be  determined  ;  but  this  is  not  always  easy,  as  many  of  the  murmurs 
are  so  loud  that  they  are  heard  all  over  the  chest.  Note  should  be  taken  as 
to  whether  the  bruit  replaces  or  is  only  heard  through,  as  it  were,  the  heart 
sounds.  A  thorough  examination  cannot,  perhaps,  be  made  at  first,  as  it  is 
unwise  to  expose  a  weakly  infant  too  much,  and,  moreover,  the  possibility  of 
a  pericardial  friction  sound  in  newly  born  infants  must  not  be  forgotten. 
Any  external  congenital  malformation  would  suggest  that  the  heart  defect 
was  the  result  of  some  arrest  of  development  or  some  abnormal  development 
rather  than  due  to  endocarditis. 

The  prognosis  is,  of  course,  bad,  but  much  uncertainty  must  necessarily 
exist,  as  the  diagnosis  of  the  exact  form  of  lesion  present  often  cannot  be 
made.  The  more  cyanosis  present  the  worse  is  the  prognosis,  as,  in  infants 
at  least,  there  is  a  great  liability  to  meningeal  haemorrhage  taking  place, 
either  slowly  or  during  a  fit  of  crying,  vomiting,  or  coughing.  Convulsions 
may  at  any  time  supervene  and  quickly  prove  fatal.  The  venous  state  of 
the  blood  interferes  with  the  secretion  of  the  digestive  juices,  and  the  whole 
system  is  worked  at  a  disadvantage.  In  older  children  the  amount  of  hyper- 
trophy and  dilatation  must  be  taken  into  account  in  making  a  prognosis  ;  the 
larger  the  heart,  the  nearer  is  it  to  the  end  of  its  tether.  The  extent  to  which 
clubbing  of  the  fingers  is  present  must  also  be  considered. 

Patent  Foramen  Ovale. — The  foramen  ovale  allows  of  the  passage  or 
blood  from  the  right  to  the  left  auricle  during  foetal  life  (see  fig.  75),  but  closes 
up  shortly  after  birth  if  there  is  no  obstruction  to  the  circulation  of  blood 
in  the  pulmonary  system,  and  consequent  increased  blood  pressure  on  the 
right  side  of  the  heart.  If,  on  the  other  hand,  the  lungs  are  only  partially  ex- 
panded, remaining  in  part  in  the  foetal  condition,  a  portion  of  the  blood  which 
under  normal  conditions  would  enter  the  pulmonary  circulation  escapes  it  by 
passing  directly  from  the  right  heart  to  the  left  through  the  foramen  ovale. 
Repeated  attacks  of  bronchitis  after  birth  may  have  a  similar  effect  in  pre- 
venting the  closure  of  the  foramen  ovale.  The  further  history  of  such  cases 
is  uncertain,  but  there  is  reason  to  suppose  that,  if  the  child  remains  free 
from  pulmonary  trouble,  the  foramen  ovale  may  close,  or  at  least  allow  of 
but  little  mixture  of  the  blood  of  the  auricles,  and  be  therefore  of  but  slight 
detriment  to  the  patient.  It  is  not  uncommon  to  meet  with  such  cases  in 
children  a  year  or  two  old,  who  come  under  medical  treatment  for  bronchitis, 
and  in  whom  a  loud  systolic  basic  bruit  is  heard,  which  varies  in  intensity 
according  to  the  amount  of  pulmonary  trouble  present.  In  one  of  our  own 
cases,  a  child  of  thirteen  months,  there  was  much  bronchitis,  ansemia,  and 
oedema  ;  the  child  recovered  for  a  while,  but  died  of  diphtheria  nine  months 
later.  The  post^morteni  showed  the  foramen  ovale  to  be  the  size  of  a 
shilling,  partly  closed  by  membranous  bands  crossing  it ;  possibly  these  had 
produced  the  bruit  heard  during  life.  The  pulmonary  artery  was  dilated. 
An  open  foramen  ovale  is  usually  present  in  cases  where  there  is  stenosis  of 


Congenital  Heart  Disease 


399 


the  pulmonary  artery  or  tricuspid  orifice.  The  murmur  produced  by  the 
passage  of  blood  through  an  unclosed  foramen  ovale  is  heard  best  at  the  base 
of  the  heart  in  front,  and  is  also  heard  well  behind.  In  position  the  foramen 
lies  at  the  posterior  aspect  of  the  heart,  on  a  level  with  the  fifth  costal  carti- 


Pulmonary  Artery - 
R.  Auricle- 


L.  Iliac  Artery 

R.  Iliac  Artery 

■■ Internal  Iliac 


/  -/'/  Ub    ^1  'II External  Iliac 


•  Placenta 
Fig.  75. — Plan  of  Fcetal  Circulation  (Gray's  '  Anatomy'). 

lage,  where  it  joins  the  sternum,  being  behind  the  sternum  and  somewhat  to 
the  right.  Posteriorly  it  lies  just  in  front  of  the  seventh  vertebra.  There  may 
be  an  open  foramen  and  yet  no  bruit  be  heard,  as,  if  there  is  no  pulmonary 
obstruction,  there  may  be  little  or  no  rush  of  blood  through  the  orifice.  As 
the  passage  of  blood  from  auricle  to  auricle  takes  place  during  the  auricular 


400  Diseases  of  the  Circulaiory  System 

systole,  presumably  the  bruit  should  be  '  presystolic  '  in  rhythm,  immediately 
preceding  the  first  cardiac  sound.  It  can  readily  be  understood  that  it  is  not 
easy  to  distinguish  between  a  presystolic  and  systolic  bruit  in  an  infant  or 
young  child,  especially  if  there  is  some  pulmonary  trouble. 

It  is  not  uncommon  to  find  a  more  or  less  open  foramen  ovale  in  older 
children.  In  one  of  our  cases,  a  boy  of  ten  and  a  half  years  who  suffered 
from  chronic  heart  disease  and  had  had  several  attacks  of  rheumatism,  we 
found /(5.S-/  mortevi  a  large  dilated  heart  with  a  much-thickened  pericardium, 
an  abnormally  small  aorta  only  admitting  a  little  finger,  an  open  foramen 
ovale,  and  a  thickened  and  puckered  mitral  valve. 

Patent  Septum  Wentriculorum. — Unlike  the  inter-auricular  partition, 
the  septum  between  the  ventricles  becomes  complete  during  foetal  life,  usually 
during  the  third  month.  If,  however,  there  is  any  obstruction  at  the  pul- 
monary orifice,  or  any  rnalformation  which  renders  unequal  the  pressure  of 
blood  in  the  two  ventricles,  the  ventricular  septum  remains  incomplete  and 
allows  of  the  passage  of  blood  from  one  ventricle  to  the  other.  The  spot 
which  remains  open,  or  is  the  last  to  close  up,  is  the  so-called  '  undefended  spot ' 
at  the  base,  where  the  septum  intervenes  between  the  mitral  and  tricuspid 
valves,  and  is  normally  the  thinnest  and  most  membranous.  An  incomplete 
septum  is  usually  associated  with  pulmonary  obstruction,  or  is  found  in 
cases  where  the  aorta  arises  from  both  ventricles,  or  where  there  is  trans- 
position of  the  great  vessels.  In  some  few  cases  it  appears  to  be  a  primary 
defect  arising  from  arrest  of  development  or  some  unknown  cause.  In  such 
cases  the  child  may  live  several  years,  the  heart  becoming  enlarged,  more 
particularly  on  account  of  the  left  ventricle  undergoing  dilatation  and  hyper- 
trophy in  its  efforts  to  maintain  sufficient  tension  in  the  arteries  during  the 
systole,  while  under  the  disadvantage  of  its  contents  being  in  part  forced  into 
the  more  feebly  acting  right  ventricle.  The  murmur  produced  is  loud  and 
rough,  replacing  the  first  sound  ;  it  is  heard  loudest  over  the  lower  part  of 
the  sternum,  but  is  well  conducted  to  the  seat  of  cardiac  impulse.  It  is  also, 
if  loud,  heard  both  in  the  axilla  and  posteinorly.^ 

Stenosis  of  the  Pulmonary  and  Tricuspid  Orifices. — If  an  endocarditis 
occur  during  fcetal  life,  especially  during  the  early  period,  it  is  apt  to  affect 
the  pulmonary  and  tricuspid  valves,  the  liability  of  the  valves  on  the  left  side 
being  greater  towards  the  end  of  foetal  life,  as  more  and  more  work  is  imposed 
upon  the  left  heart.  In  some  cases  a  complete  stenosis  of  the  pulmonary 
and  tricuspid  orifices  takes  place,  the  heart  becoming  trilocular.  Thus,  in  the 
case  of  an  infant  markedly  cyanotic  during  life,  but  who  lived  for  four 
months,  it  was  found  that  the  pulmonary  orifice  was  completely  closed,  the 
tricuspid  only  admitted  a  crowquill,  and  the  right  ventricle  was  contracted  and 
diminutive.  There  was  an  open  foramen  ovale,  and  the  pulmonary  circula- 
tion had  been  maintained  by  an  open  ductus  arteriosus,  the  lungs  being  thus 
supplied  by  the  aorta.  In  other  cases  where  the  stenosis  of  the  pulmonary 
artery  is  only  partial,  the  patient  may  live  for  years  or  even  reach  adult  life  ; 
there  is  usually  an  open  foramen  ovale,  or  ductus  arteriosus,  or  defective 
interventricular  septum  ;  cyanosis  is  mostly  present,  of  a  more  or  less  high 
grade  ;  the   child   easily   gets  out   of  breath,  is  backward  in  talking   and 

1  See  case  reported  by  Hutton  in  the  Abstracts,  Children's  Hospital,  Pendlebury,  1883, 
p.  45  ;   and  Keating  and  Edwards,  Arch,  of  Pcsdiatrics ,  p.  134,  1887. 


Congenital  Heart  Disease 


'401 


getting  on  its  feet,  and  is  incapable  of  any  great  amount  of  exertion.  The 
murmur  present  is  usually  loud,  superficial,  and  rasping,  being  best  heard 
over  the  pulmonary  valves,  over  the  second  left  costal  cartilage  near  the 
sternum.  There  may  be  signs  of  dilatation  of  the  right  ventricle,  such  as 
epigastric  pulsation. 

This  is  perhaps  the  commonest  form  of  congenital  heart  disease  found 
in  children  who  have  survived  infancy  and  early  childhood.  Such  children 
may  live  to  grow  up,  but  are  apt  to  suffer  from  tuberculosis  or  to  be  carried 
off  by  bronchitis  or  pneumonia.  Post-natal  endocarditis  is  sometimes 
superadded.  The  diagnosis  is  not  always  easy  between  pulmonary  stenosis 
and  open  foramen  ovale  without  other  lesion,  especially  as  the  bruit  heard 
may  result  from  the  presence  of  both  lesions.     In  pulmonary  stenosis  there 


-C 


Fig.  76. — Congenital  Heart  Disease,  from  a  child  aged  19  months.     Stenosis  of  the  pulmonary- 
artery,     a,  aorta  ;  b,  pulmonary  artery  ;  c,  patent  ductus  arteriosus. 


is  more  likely  to  be  cyanosis  and  a  dilated  right  ventricle,  with  the  murmur 
confined  to,  and  heard  loudest  in  the  pulmonary  area.  Cadet  de  Gassicourt 
has  reported  a  case  where  a  bruit  was  produced  through  enlarged  glands 
pressing  on  the  pulmonary  artery. 

Stenosis  of  the  Aorta  or  IVlitral  Valve. — In  some  cases  there  appears 
to  be  a  congenital  smallness  of  the  aorta  and  arterial  system,  though  it  most 
commonly  is  the  result  of  undergrowth,  being  secondary  to  some  other  cardiac 
lesion,  by  reason  of  which  the  arterial  system  is  imperfectly  supplied  with 
blood.  An  endocarditis  occurring  late  in  foetal  life  sometimes  affects  the 
aortic  valves,  and  an  endocarditis  may  also  occur  after  birth,  and  still  further 
deform  or  pucker  the  valves.  In  such  cases,  if  there  is  marked  obstruction 
at  the  aortic  valves,  the  ductus  arteriosus  may  remain  open,  and  some  of  the 

D  D 


402  Diseases  of  the  Circulatory  System 

blood  may  pass,  as  it  does  during  fcetal  life,  from  the  pulmonary  artery  into 
the  aorta,  without  passing  through  the  lungs  ;  the  left  ventricle  becomes 
hypertrophied.  When  the  stenosis  is  only  moderate,  life  may  be  prolonged 
for  many  years.     Stenosis  of  the  mitral  valves  may  also  occur. 

Transposition  of  the  Aorta  and  Pulmonary  Artery. — This  curious 
malformation  is  not  uncommon  ;  the  foramen  ovale  and  ventricular  septum 
remain  open.  Lite  is  rarely  prolonged  for  more  than  a  few  months  ;  there 
is  much  cyanosis,  but  no  bruit  is  present.  A  diagnosis  during  life  is  hardly 
possible.  Of  the  many  other  malformations  or  arrests  of  development,  such 
as  a  heart  consisting  of  single  auricle  and  ventricle,  or  a  three-chambered 
heart,  it  is  unnecessary  to  speak. 


Fig.  77.  — Same  heart  as  fig.  76.  Right  ventricle  opened,  a,  aorta  arising  from  both  ventricles  ; 
b,  pulmonary  artery,  valves  adherent,  only  admits  a  large  probe  ;  c,  incomplete  interventricular 
septum  ;  d,  tricuspid  valves. 


Diseases  of  the  Pericardium 

In  a  few  cases  a  congenital  absence  of  the  pericardium  or  some  defect 
in  the  pericardium  has  been  recorded.  In  some  cases  a  hernia  or  diver- 
ticulum has  been  present  ;  these  congenital  defects  are  of  little  practical 
interest. 


Pericarditis 

Etiology. — In  children,  as  in  adults,  the  most  important  association  of 
pericarditis  is  with  rheumatism,  acute  or  subacute,  as  it  arises  more  often 
during  a  rheumatic  attack  than  under  any  other  condition.  An  exception  to 
this  however  occurs,  for  in  children  under  three  years  of  age  rheumatism  is 
an  uncommon  ailment,  and  pericarditis  when  present  is  most  frequently  the 
result  of  an  extension  of  the  inflammation  from  a  pleuro-pneumonia.  or 
empyema    or  arises  in  association  with  such  attacks.     It  is  by  no  means 


Pericarditis  403 

uncommon  to  hear  a  pericardial  friction  sound  during  an  attack  of  pneumonia 
in  young  children,  or  perhaps  to  discover /^^^  inorteniX\\?iX  a  pericarditis  has 
taken  place  in  a  case  which  was  looked  upon  during  life  as  one  of  simple 
broncho-  or  pleuro-pneumonia.  In  such  cases,  if  they  recover,  a  chronic 
pericardial  effusion,  sometimes  purulent,  may  remain  after  the  pulmonary 
lesion  has  been  recovered  from. 

Pericarditis  occasionally  occurs  during  an  attack  of  scarlet  fever,  either 
associated  with  synovitis,  or  it  may  be  in  the  absence  of  any  joint  com- 
plications. It  occurs  also  during  the  course  of  post-scarlatinal  nephritis, 
as  a  result  of  a  ur^emic  condition,  and  under  such  circumstances  must  be 
looked  upon  as  of  extremely  evil  augury.  It  may  occur  during  septiccemia, 
to  whatever  cause  this  may  be  attributed,  or  in  periostitis  and  ostitis,  and  we 
have  known  it  supervene  in  an  attack  of  influenza. 

Pericarditis  occurring  in  a  child  over  three  years  of  age  is  most  frequently 
associated  with  the  rheumatic  state.  Not  that  it  only  occurs  during  an  attack 
of  acute  rheumatism,  for  it  may  supervene  when  there  is  no  joint  pain  what- 
ever, or  when  the  joint  pain  is  slight  ;  but  it  occurs  in  a  rheumatic  individual, 
one  who  has  already  suffered  from  an  attack,  or  who  suffers  from  some  of 
the  associations  of  rheumatism,  such  as  chorea,  erythema  nodosum,  or  endo- 
carditis. Pericarditis  is  apt  to  crop  up  in  an  unexpected  and  unexplained 
manner,  and  it  should  be  carefully  looked  for  whenever  indefinite  precordial 
or  epigastric  pain  is  complained  of.  It  must  be  borne  in  mind  that,  like 
pleurisy,  it  occurs  in  an  extremely  mild  form  ;  a  pericardial  rub  may  be  heard 
unexpectedly  in  the  absence  of  any  definite  symptoms  in  children  who  are 
going  about  and  make  no  complaint  of  pain  or  dyspnoea.  These  attacks 
pass  away,  and  presumably  leave  more  or  less  of  adhesions  between  the 
visceral  and  parietal  layers  of  the  pericardium.  Does  pericarditis  recur  ? 
No  doubt  it  does,  in  spite  of  fibroid  adhesions  and  damage  to  the  serous 
layer  by  former  attacks. 

Cases  of  pericarditis  occurring  during  foetal  life  have  been  recorded  by 
Billard,  Bednar,  and  others.  It  also  occurs  in  the  septicaemia  of  the  newly 
born,  secondary  to  an  inflammatory  condition  of  the  cord. 

Symptoms. — The  subjective  symptoms  are  usually  ill  defined,  especially 
in  young  children,  and  are  of  comparatively  little  importance  as  helps  to 
diagnosis.  The  signs  and  symptoms  mostly  to  be  relied  on  are:  (i)  The 
presence  of  a  pericardial  friction  sound.  (2)  An  increased  area  of  cardiac 
dulness  proportionate  to  the  effusion  present.  (3)  The  disappearance  of  the 
apex  beat,  or  the  position  of  the  apex  beat  is  raised  and  its  area  extended. 
(4)  There  is  heart  pain  and  perhaps  tenderness  on  pressure  over  the  cardiac 
region,  (i)  A  pericardial  friction  sound  can  hardly  be  overlooked  if  carefully 
listened  for,  and  is  not  likely  to  be  mistaken  for  valvular  murmurs,  except, 
perhaps,  in  the  case  of  infants  the  subject  of  congenital  heart  disease,  the 
murmur  in  such  cases  being  often  harsh  and  superficial.  It  must  not  be  for- 
gotten that  the  presence  of  a  friction  sound  is  not  incompatible  with  a  large 
amount  of  effusion  into  the  pericardial  sac.  It  mostly,  however,  disappears 
as. effusion  takes  place,  and  reappears  as  the  liquid  becomes  absorbed. 
(2)  As  effusion  takes  place  into  the  sac,  the  area  of  cardiac  dulness  is  neces- 
sarily increased  in  proportion  to  the  amount  of  fluid  present.  The  peri- 
cardium of  a  healthy  child  (age  6-9  years)  when  fully  distended  contains, 


404  Diseases  of  tlie  Circidatory  System 

according  to  Sibson,  about  6  oz.,i  but  much  larger  quantities  than  this  are 
often  present  :  the  effect  of  the  distension  of  the  sac  with  fluid  is  to  increase 
the  cardiac  dulness  laterally,  and  in  an  upward  direction,  the  lungs,  especially 
the  left,  being  pushed  on  one  side,  so  that  the  dulness  extends  to  the  second 
left  costal  cartilage,  or  even  as  high  as  the  clavicle,  and  over  a  corresponding 
portion  of  the  sternum.'  In  lesser  effusions  the  fluid  tends  to  accumulate  in 
the  lowest  part,  and  so  modifies  the  dulness  in  a  lateral  direction.  (3)  The 
cardiac  impulse  disappears  and  the  sounds  become  faint  if  the  effusion  is 
large,  as  a  layer  of  fluid  is  interposed  between  the  heart  and  the  chest  walls. 
Instead  of  the  apex  beat  disappearing,  it  may  be  diffused  and  raised  so  as  to 
be  palpable  or  visible  in  the  third  and  fourth  spaces,  as  pointed  out  by 
Sibson.  (4)  Pericarditis  may  take  place  without  any  complaint  of  pain  on 
the  part  of  the  patient,  and  hence  may  be  easily  overlooked  in  a  mild  case. 
In  severe  cases  the  pain  is  referred  to  the  cardiac  region,  and  pressure  with 
the  fingers  or  stethoscope  causes  pain. 

The  discovery  of  a  friction  sound  is  usually  the  first  thing  to  call  at- 
tention to  the  attack.  There  may  be  only  a  slight  rub  or  a  loud  grating 
sound  heard  all  over  the  chest.  At  this  stage,  where  there  is  no  fluid  present, 
presuming  there  is  no  valvular  disease  or  dilatation,  there  is  no,  or  but  little, 
dyspnoea,  probably  more  or  less  pain  in  the  chest,  quickened  pulse  and 
moderate  fever.  The  amount  of  fever  present  is  variable,  seldom  very  high — 
101°  F.  to  103°  F.  in  a  severe  case  ;  the  temperature  usually  falls  by  lysis 
towards  the  end  of  the  week.  The  rub  may  disappear  in  a  few  days  in  con- 
sequence of  adhesions  being  formed.  On  the  other  hand,  the  friction  sounds 
may  entirely  or  in  part  disappear  in  consequence  of  effusion  taking  place  ; 
as  the  effusion  increases  dyspnoea  becomes  more  marked  :  at  first  it  is 
slight,  but  if  the  effusion  becomes  large  the  dyspnoea  increases,  coming  on 
in  paroxysms  accompanied  by  cyanosis,  and  there  is  perhaps  a  small, 
irregular  pulse.  It  must  not  be  forgotten  that  a  considerable  effusion  may  be 
present,  and  yet  a  loud  friction  sound  be  heard,  caused  by  a  small  portion 
of  the  roughened  layers  of  pericardium  coming  in  contact.  Death  may  be 
sudden  at  this  stage,  especially  in  those  cases  where  pericarditis  supervenes 
on  old  heart  mischief,  and  the  cardiac  walls  have  become  degenerated.  In 
other  cases  the  fluid  is  gradually  absorbed,  the  friction  is  again  heard  more 
or  less  intensely,  and  finally  disappears  as  adhesion  takes  place. 

No  inflammatory  affection  differs  more  in  intensity  than  rheumatic  peri- 
carditis. There  is  little  doubt  that  slight  attacks  occur  which  are  over- 
looked, for  a  pericardial  friction  sound  is  heard  at  times  when  least  expected, 
and  disappears  again  without  producing"  any  symptoms  of  importance,  or 
without  the  child  having  been  ill,  or  it  may  be  discovered  during'  an  inter- 
current attack  of  scarlet  fever  or  pneumonia.  On  the  other  hand,  acute 
pericarditis,  or  '  acute  carditis,'  as  Dr.  Sturges  has  called  it,  is  a  severe  and 
dangerous  affection,  especially  when  it  supervenes  in  patients  whose  mitral 
valves  have  been  damaged  by  attacks  of  endocarditis,  and  dilatation  of  the 
heart  cavities  has  occurred.  The  damaged  heart  has,  when  surrounded  by 
lymph  and  fluid,  to  struggle  with  an  increased  load,  and  no  wonder  the 
prominent  feature  of  the  attack  is  cardiac  failure.      In  these    severe   cases 

^  In  enlarged  hearts  at  this  age,  the  pericardium  may  contain  two  or  three  times  this 
amount. 


Pericarditis  405 

there  is  a  quickened  and  perhaps  irregular  and  intermittent  pulse,  orthopnoea, 
vomiting,  with  an  anxious  and  worn  expression  of  face.  In  the  worst  cases, 
when  the  effusion  of  fluid  is  great,  the  patient  has  an  ashen  or  cyanotic  look, 
he  sits  up  in  bed  leaning  forward,  and  bringing  all  the  extra  muscles  of 
respiration  into  play  in  the  struggle  for  breath.  Oedema  of  the  extremities, 
ascites,  and  pleural  effusion  may  be  present. 

In  the  slighter  cases  of  pericarditis,  loose  adhesions  or  attachments  may 
take  place  between  the  two  layers  of  the  pericardium.  The  result  of  a  single 
atiack  may  be  unimportant,  but  if  there  are  repeated  attacks,  and  they  are 
severe,  tough  and  thick  adhesions  are  formed.  The  heart  is  thus  surrounded 
by  a  thick  fibrous  coat,  perhaps  one-eighth  to  a  quarter  of  an  inch  in  thick- 
ness, which  clogs  and  impedes  the  systole  of  the  ventricles.  Gradual 
dilatation  of  all  the  cavities  takes  place,  with  thinning  of  their  walls.  This 
condition  of  things  is  naturally  made  worse  by  an  endocarditis,  which 
thickens  and  deforms  the  mitral  and  perhaps  the  tricuspid  valves.  Thus,  as 
an  illustration  of  these  results,  we  may  refer  to  the  following  case.  A  girl  of 
twelve  years,  who  had  suffered  from  chronic  heart  disease  for  some  years  ;  at 
\.\\Q  post  mortem  the  heart  with  the  attached  pericardium  and  containing  clot 
weighed  twenty-two  ounces,  the  pericardium  was  thick  and  adherent  and 
leathery,  all  the  cavities  were  dilated,  the  mitral  valve  had  suffered  from  old 
and  recent  endocarditis,  the  tricuspid  orifice  and  the  pulmonary  ailery  were 
abnormally  wide,  the  aorta  was  small,  just  admitting  the  little  finger,  and 
indeed  the  aorta  and  its  bi^anches  were  no  larger  than  those  of  a  child  ot 
three  years.  No  doubt  in  this  case  the  aorta  had  failed  to  develop  normally 
on  account  of  the  small  amount  of  blood  which  passed  through  it.  In  these 
cases  it  is  possible  that  the  dilatation  is  really  an  acute  and  rapid  process 
occurring  during  attacks  of  rheumatism,  and  not  entirely  the  result  of  an 
adherent  and  thickened  pericardium. 

There  can  be  little  doubt,  as  both  Dr.  O  Sturges  and  more  recently  Dr. 
D.  B.  Lees  have  pointed  out,  that  what  often  passes  as  pericarditis  is  in  reality 
acute  carditis  or  myocarditis — that  is,  the  changes  are  not  confined  to  the 
pericardium,  but  the  muscles  of  the  heart  walls  may  suffer  severely  from  the 
effects  of  the  rheumatic  toxines,  and,  as  a  consequence,  the  muscular  walls 
are  weakened  and  the  cardiac  cavities  become  dilated.  This  dilatation  is 
an  active  process  in  acute  cases,  and  is  not  dependent  upon  mitral  regurgitation, 
the  result  of  endocarditis.  Dr.  Lees  also  points  out  that  acute  dilatation  may 
take  place  during  a  rheumatic  attack  without  the  assistance  of  pericarditis, 
though  it  is  much  more  pronounced  if  pericarditis  is  present.  A  first  attack 
of  rheumatism  may  lead  to  an  acute  dilatation  of  the  heart  if  the  attack  is  a 
sharp  one,  and  if  it  does  not  prove  fatal  it  may  leave  a  much-dilated  condition 
and  perhaps  adherent  pericardium. 

An  effusion  into  the  pericardium,  like  an  effusion  into  the  pleural  cavity, 
may  be  chronic.  It  sometimes  happens,  as  we  have  already  pointed  out, 
especially  in  young  children,  that  a  pericardial  and  pleural  effusion  takes 
place,  the  latter  becomes  absorbed,  and  adhesions  form  while  the  peri- 
cardium remains  distended  with  fluid.  If  the  child  is  seen  for  the  first  time 
when  this  has  occurred,  an  error  in  diagnosis  is  very  easy,  as  the  dulness 
caused  by  a  distended  pericardium  shades  away  into  the  impaired  resonance 
given  by  a  compressed  and  adherent  left  lung.     We  have  several  times  seen 


406  Diseases  of  the  Circulatory  System 

in  young  children  fluid  aspirated  from  the  pericardium  by  a  needle  passed 
into  the  axilla,  when  it  was  believed  the  fluid  was  being  drawn  from  the  left 
pleural  cavity.  In  these  cases,  it  was  found  at  Xh&  post-mortem  examination 
the  needle  had  passed  through  the  compressed  left  lung  and  entered  the 
distended  pericardium. 

A  chronic  pericardial  effusion  is  sometimes  present  in  tubercular  sub- 
jects, after  the  manner  of  a  peritoneal  effusion  :  this  may  be  of  long 
standing,  and  the  diagnosis  may  be  difficult,  as  the  effusion  may  be 
associated  with  a  mediastinitis  and  may  suggest  the  presence  of  mediastinal 
tumour.     This  was  so  in  the  following  case  : 

Chronic  Pericarditis  and  Peritonitis,  Contracted  Mitral,  General  Miliary  Tuber- 
culosis.— John  Hy.  P.,  aged  7  years.  Mother  states  he  has  always  been  a  healthy  boy  till 
four  months  ago,  when  he  had  bronchitis  ;  has  been  wasting  ever  since  ;  his  belly  has 
been  swelling  since.  Admitted  August  27,  1885.  Is  an  anaemic,  flabby  boy,  with  dis- 
tended abdomen,  evidently  containing  much  peritoneal  fluid ;  right  side  of  chest  is 
normal ;  the  left  is  quite  dull  in  front,  reaching  to  the  clavicle  above,  and  shading  away 
in  the  stomach  resonance  and  into  axilla,  which  is  also  resonant ;  the  whole  cardiac  area 
is  included  in  the  dull  area,  the  dulness  extends  to  the  right  just  beyond  the  right  sternal 
line  ;  posteriorly  the  percussion  note  is  normal  ;  over  the  dull  area  there  is  bronchial 
breathing  both  with  ex-  and  inspiration  ;  there  are  no  moist  sounds  ;  the  cardiac  impulse 
is  not  visible  or  palpable ;  cardiac  sounds  normal ;  the  veins  on  the  chest  are  enlarged  and 
tortuous  ;  there  is  marked  ascites  ;  the  liver  is  enlarged  ;  the  spleen  not  felt ;  urine  not 
albuminous.  September  24. — Boy  continues  much  in  same  state  ;  less  ascites  ;  the 
temperature  continues  normal  or  subnormal ;  he  does  not  appear  ill  or  in  any  way 
uncomfortable  ;  the  glands  in  the  neck  under  jaw  are  enlarging.  November  11. — Went 
home  for  a  while.  Readmitted  December  10,  1886.  Has  been  fairly  well  at  home,  except 
he  has  bad  cough  and  his  belly  has  swollen  more  ;  physical  signs  in  chest  much  the 
same  ;  there  is,  however,  more  dyspnoea  ;  the  face  has  a  bluish  tinge,  and  the  superficial 
veins  on  chest  more  distended ;  exploration  of  chest  in  dull  area  with  a  hypodermic 
syringe  ;  some  straw-coloured  coagulable  fluid  like  serum  was  withdrawn.  January  22. — 
Has  been  getting  worse  for  some  weeks  past ;  temperature  has  since  December  13  been 
99°-ioi°-i03°  ;  the  physical  signs  have  not  materially  altered,  except  there  is  some 
impaired  resonance  now  at  base  of  left  lung  behind.  January  24. — Has  been  vomiting; 
pulse  96  ;  irregular  and  intermittent ;  temperature  98°-io2°.  January  25. — Continues  to 
vomit ;  the  ascites  has  much  diminished.  Died  January  27. — Post-mortem. — Some 
emaciation  ;  some  bulging  over  cardiac  area  ;  on  opening  chest  it  is  seen  the  pericardium 
is  distended,  pushing  the  left  lung  away  to  the  left  out  of  sight,  the  edge  of  the  right  lung 
partly  overlapping  pericardium  ;  there  is  a  complete  matting  together  of  the  pericardium 
and  mediastinal  glands  with  excess  of  fibre-tissue ;  the  mediastinal  glands  are  enlarged, 
containing  miliary  tubercle  ;  some  are  shrunken  and  pigmented  ;  the  right  lung  is  normal  ; 
the  left  is  compressed,  surrounded  by  old  adhesions  and  recent  miliary  tubercle ;  on 
section  it  is  condensed  ;  recent  pulmonary  apoplexy  ;  the  pericardium  is  adherent  to  the 
parts  around  ;  on  cutting  into  it  its  walls  are  nearly  \  inch  thick,  it  contains  2  or  3  oz.  of 
serum  and  much  loose  granular  lymph  ;  heart  somewhat  small,  lymph  on  the  surface  ; 
mitral  valve  only  admits  forefinger  ;  tricuspid,  2^  fingers  ;  edges  of  mitral  valve  hard  and 
sclerotic  ;  left  auricle  wall  thickened  ;  left  ventricle  cavity  small ;  right  ventricle  dilated  ; 
a  few  ounces  of  fluid  in  peritoneum  ;  omentum  indurated,  covered  with  recent  miliary 
tubercles  ;  large  and  small  intestines  covered  with  miliary  tubercles  ;  no  ulcers  internally  ; 
liver  adherent  to  the  diaphragm  and  covered  with  miliary  tubercles  ;  section  fatty  ;  kidneys, 
a  few  cheesy  tubercles  ;  spleen  normal ;  brain,  lymph  in  Sylvian  fissures,  around  cere- 
bellum, and  in  interpeduncular  space  ;  fluid  in  the  ventricles  ;  tubercle  on  the  vessels. 

Chronic  pericardial  effusions  are  apt  to  become  purulent,  and  in  rare  cases 
the  pus  may  find  its  way  to  the  surface  after  the  fashion  of  an  empyema  ;  this 
happened  in  one  of  our  own  cases,  a  child  of  eighteen  months,  the  abscess 


Pericarditis — Endocarditis  407 

pointing  near  the  tip  of  the  sternum  ;  after  the  abscess  was  opened  the  child 
died  of  exhaustion,  and  the  diagnosis  was  verified  post  iiiorteni.  In  such 
cases  there  is  much  difficulty  in  deciding  as  to  the  origin  of  the  pus  :  as  to 
whether  the  abscess  is  a  collection  of  pus  finding  its  way  out  from  the 
mediastinum  or  from  the  pericardium.  It  may  also  be  a  local  empyema  or 
periosteal  abscess. 

CoDiplications.^ln  rheumatic  pericarditis,  endocarditis  is  exceedingly 
likely  to  occur  during  the  attack.  Pleurisy  or  pleuro-pneumonia  may  be 
present ;  more  rarely  peritonitis  and  meningitis. 

Diagnosis. — A  pericardial  friction  sound  is  not  likely  to  be  confounded 
v.ith  anything  else,  unless,  perhaps,  it  is  an  exo-cardiac  sound,  such  as  is  pro- 
duced by  the  external  surface  of  the  pericardium  rubbing  against  a  roughened 
pleura  ;  but  this  latter  is  heard  only,  or  at  any  rate  more  loudly,  during 
inspiration.  The  difficulty  most  likely  to  occur  is,  in  a  case  in  which  there 
is  admittedly  old  cardiac  mischief,  to  distinguish  between  dulness  due  to  the 
presence  of  fluid  and  that  due  to  a  dilated  heart.  To  anyone  who  has  care- 
fully watched  a  case  from  the  commencement  of  the  heart  disease  this  diffi- 
culty may  be  small  ;  but  in  cases  which  are  suffering  from  great  dyspnoea  and 
distress,  in  which  pericarditis  and  dilated  ventricles  exist  together,  it  is  often 
difficult  to  decide  when  the  child  is  seen  for  the  first  time  what  amount  of  fluid 
is  present  and  what  share  it  takes  in  the  production  of  the  cardiac  distress.  It 
must  be  borne  in  mind  that  if  the  amount  of  fluid  is  excessive,  there  is  dul- 
ness as  high  as  the  left  second  intercostal  space.  In  a  large  dilated  heart 
there  will  be  bulging  of  the  chest  walls,  and  an  extended  area  of  pulsation 
in  part  outside  the  left  nipple  line.  It  has  been  pointed  out  by  several 
writers  (Rotch,  Dickenson)  that  dulness  extending  to  the  right  fifth  inter- 
space is  probably  due  to  fluid  ;  this  however  is  not  by  any  means  always  the 
case,  but  may  be  due  to  a  dilated  right  heart. 


Endocarditis 

Inflammation  of  the  membrane  lining  the  heart,  more  especially  that 
part  which  covers  the  valves,  occurs  at  all  periods  of  life.  It  may  attack  the 
fcetus  and  then  usually  affects  the  pulmonary  or  tricuspid  valves  ;  but  if  it 
occur  in  the  last  few  weeks  of  fcetal  life  it  may  affect  the  mitral  and  aortic 
valves.  It  may  also  occur  during  the  two  or  three  years  succeeding  birth  ; 
it  is,  however,  less  common  at  this  period  than  later,  though  it  is  probably 
often  overlooked.  It  is  common  during  the  later  periods  of  childhood  and 
youth.  Like  pericarditis,  its  usual  association  is  with  the  rheumatic  state, 
not  that  there  is  necessarily  marked  tenderness  of  the  joints  and  high  fever, 
but  the  patient  exhibits  some  of  the  symptoms  or  associations  of  rheumatism, 
such  as  chorea,  or  erythema  nodosum,  or  he  has  suffered  from  undoubted 
joint  troubles  in  the  past.  During  an  attack  of  rheumatism,  children  are 
especially  prone  to  suffer  from  endocarditis,  and  the  proportion  of  those  who 
do  suffer  is  greater  than  in  the  case  of  adults,  being  in  the  case  of  children 
perhaps  75-80  per  cent.  ;  in  adults  the  proportion  must  be  far  less  than  this. 
Endocarditis  also  occurs  in  scarlatinal  synovitis  ;  the  heart  does  not,  however, 
so  often  suffer  here  as  in  simple  rheumatism.  In  nephritis,  in  pyjemia,  and 
during  attacks  of  any  of  the  zymotic  fevers,  especially  diphtheria,  endocarditis 


4o8 


Diseases  of  the  Circulatory  System 


may  occur.  In  all  febrile  conditions  a  difficulty  may  arise  in  the  diagnosis, 
in  distinguishing  murmurs  due  to  organic  disease  from  hsemic  murmurs. 
During  fever  the  circulation  is  disturbed  and  the  cardiac  beats  increase  in 
number,  the  first  cardiac  sound  being  wanting  in  sharpness,  or  there  may 
be  a  '  murmurish  '  sound  heard  ;  if  this  disappears  during  convalescence  we 
are  hardly  justified  in  saying  that  an  endocarditis  has  existed.  That  endo- 
carditis does  occur  at  times  during  an  attack  of  scarlet  fever  or  during  con- 
valescence is  certain  ;  it  is,  however,  rare  to  find  the  valves  affected  in  a  fatal 
case  of  scarlet  fever. 

Malignant  or  ulcerative  endocarditis  arises  in  some  instances  in  connec- 
tion with  the  rheumatic  state,  being  engrafted  on  to  an  ordinary  rheumatic  en- 
docarditis ;  it  occurs  in  connection  with  acute  nephritis,  suppurative  periostitis 
and  osteomyelitis.  It  appears  sometimes  to  follow  scarlet  fever.  Recent 
observations  have  shown  the  presence  of  septic  micro-organisms,  such 
as  streptococci,  staphylococci,  and  Fraenkel's  pneumonia  diplococci  on 
the  valves  in  malignant    endocarditis,  and    it  would  appear  as  if  a  simple 


ssa 

iBBBBBBBBBBBBBBi'SBBBiTSBBUiBBBBaBBBSaaBaerSBBBB 

ligBimBaSeaii^^SaMiBSBP^*"' 


Fig.  78. — Temperature  Chart  of  a  case  of  Endocarditis  supervening  on  the  sixth  day  of  a 
mild  Scarlet  Fever  ;  there  were  no  joint  lesions,  the  bruit  persisted,  and  dilatation  of  the 
left  ventricle  followed. 


endocarditis  afforded  a  suitable  soil  for  the  development  of  these  pyogenic 
micro-organisms.  We  have  several  times  got  cultivations  of  streptococci 
on  gelatine  from  blood  drawn  from  the  finger  in  cases  of  malignant  endo- 
carditis. 

The  symptoms  of  simple  endocarditis,  such  as  occurs  during  rheumatism, 
are  not  distinctive.  There  is  often  precordial  pain,  perhaps  some  dyspnoea, 
usually  some  fever  of  an  intermittent  type  (see  fig.  78),  though  this,  in  some 
instances,  may  be  due  to  the  rheumatism  present  ;  indeed,  the  only  symptom 
upon  which  any  reliance  can  be  placed  is  the  presence  of  a  bruit :  it  is  certain, 
however,  that  endocarditis  may  exist  without  a  bruit  being  present.  It 
sometimes  happens  that  during  an  attack  of  rheumatism  or  chorea  the  most 
careful  examination  may  fail  to  detect  a  bruit,  and  yet,  if  the  patient  is 
examined  a  month  or  two  after,  a  bruit  is  detected,  which  comes  rather  as  a 
surprise.  In  the  vast  majority  of  cases  it  is  the  mitral  orifice  which  is 
affected,  a  murmur  being  heard  which  replaces  or  accompanies  the  first 
sound  at  the  apex.  Dr.  O.  Sturges  points  out  that  in  some  cases  a  faint 
murmur  heard  at  the  top  of  the  ensiform  cartilage,  indicating  regurgitation 


Endocarditis  409 

at  the  tricuspid  orifice,  precedes  the  mitral  bruit,  the  tricuspid  regurgitation 
being  due  to  Ijack  pressure  through  the  lungs.  The  constitutional  disturbance 
is  but  slight,  or  at  least  it  is  impossible  to  separate  the  symptoms  produced 
by  the  endocarditis  from  those  produced  by  the  rheumatism.  When  a  re- 
current attack  of  endocarditis  takes  place  in  a  case  of  old  heart  disease,  where 
there  is  mitral  regurgitation  and  a  bruit  present,  it  is  rarely  possible  to  make 
a  definite  diagnosis. 

When  the  endocarditis  is  of  the  malignant  or  'ulcerative'  variety,  the 
constitutional  symptoms  are  usually  much  more  marked,  and  are  those  of 
septicaemia  engrafted  on  to  heart  disease.  It  may  supervene  in  a  subject 
already  suffering  from  rheumatic  heart  disease,  post-scarlatinal  nephritis,  or 
periostitis.  In  some  cases  the  symptoms  are  very  hke  those  of  acute  tuber- 
culosis, and  in  one  case  which  came  under  our  notice  a  death  certificate  to 
that  effect  was  given,  a  subsequent  post-mortem  showing  the  real  nature  ot 
the  disease  to  be  acute  endocarditis.  In  such  cases  the  bruit  may  be  of  a 
musical  character  and  accompanied  by  a  thrill  ;  the  aortic  valves  may  also 
be  aft'ected  and  be  the  seat  of  a  bruit.  There  is  usually  precordial  pain,  often 
pain  in  the  left  shoulder  ;  a  hectic  temperature  rising  to  103°  or  104°  in  the 
evening  and  falling  in  the  morning,  an  enlargement  and  often  tenderness  of 
the  spleen.  The  urine  is  usually  albuminous,  often  highly  so.  There  may 
be  joint  pain  and  some  of  the  phenomena  of  embolism.  In  one  of  our  own 
cases  there  was  aneurism  due  to  embolism  of  the  middle  cerebral  artery  ;  in 
another  embolism  of  the  lenticular  striate  artery. 

In  any  case  of  undoubted  heart  disease  with  intermittent  pyrexia,  malig- 
nant endocarditis  should  be  suspected,  especially  if  there  is  enlargement  of 
the  spleen  and  albuminuria.  The  aortic,  tricuspid,  and  pulmonary  valves 
are  often  affected  in  malignant  endocarditis  ;  the  fact  that  an  aortic  bruit  is 
heard  in  a  case  of  acute  cardiac  disease  may  help  us  to  decide  in  favour  of 
malignant  endocarditis.  The  following  case  of  malignant  endocarditis  may 
be  taken  as  an  example  : 

Malignant  Endocaj-ditis — Embolism  of  Brain  and  Spleen. — Sarah  E.  C,  aged  ii  years. 
Mother  has  had  rheumatic  fever.  Four  children  have  died  of  wasting  and  convulsions. 
Last  Christmas  child  had  chorea  for  three  months  and  also  rheumatism.  A  month  ago 
child  complained  of  pains  in  limbs.  She  has  a  cough  and  is  short  of  breath,  but  has 
been  going  to  school  up  to  a  fortnight  ago.  Admitted  August  20,  1891.  Heart. — Apex 
beat  in  si.xth  space,  outside  nipple  line,  no  thrill,  musical  systolic  murmur  at  apex,  does 
not  replace  the  first  sound  ;  second  sound  accentuated,  no  bruit.  Lnngs,  normal.  Urine, 
trace  of  albumen.  August  27. — Child  has  improved.  There  is  a  presystolic  as  well  as  a 
systolic  bruit  ;  slight  pres)'Stolic  thrill.  Temperature  goes  to  100°  at  night.  Sep- 
tember 9. — Xo  presystolic  murmur  now;  rough  systolic  at  the  apex  well  conducted  into 
axilla.  Temperature  99°  to  103°.  At  7  P.M.  last  night  child  complained  of  pain  in  right 
arm  and  leg.  An  examination  this  morning  shows  complete  hemiplegia,  the  right  arm 
and  leg  are  paralysed  ;  there  is  also  facial  paralysis  of  the  same  side  ;  knee  jerk  diminished  ; 
plantar  reflex  present ;  slight  dropsy  of  right  eyelid  ;  hemi-anaesthesia  of  the  same  side. 
Child  not  unconscious  ;  tongue  protruded  to  right ;  speech  indistinct  and  thick ;  no  certain 
loss  of  memory  for  words  ;  she  will  give  the  names  of  common  objects  ;  no  optic  neuritis  ; 
spleen  much  enlarged,  no  albumen.  November  24. — Patient  has  been  getting  weaker 
since  last  note  and  more  antemic,  her  face  becoming  quite  pallid.  Temperature  has  varied 
from  99°  to  103°  ;  the  paralysis  is  much  the  same,  except  that  contracture  has  become 
more  marked  during  the  last  few  weeks,  and  the  knee  jerk  more  pronounced.  Early  on 
the  morning  of  November  24  she  became  unconscious,  the  breathing  stertorous  ;  she 
lingered   a  few  hours  in  this  state  and  then  sank.     Post-mortem. — Lungs. — Both  lungs 


4IO  Diseases  of  the  Circulatory  System 

studded  with  pale  infarcts,  hypostatic  pneumonia  at  bases  of  both  kings.  Heart. — Much 
enlarged,  extending  from  nipple  to  nipple  ;  some  two  ounces  of  fluid  in  the  pericardium  ; 
no  pericarditis.  Left  ventricle  dilated  and  containing  much  dark  clot ;  mitral  valve 
covered  with  large  warty  granulations  which  can  be  readily  detached ;  posterior  surface 
of  left  auricle  is  the  seat  of  numerous  granulations  ;  there  is  also  a  small  patch  on  the 
surface  of  the  ventricle,  where  there  has  been  friction  or  where  a  flap  of  the  mitral  valve 
has  impinged.  All  other  valves  are  normal.  Liver. — Congested,  nutmeg,  and  much 
enlarged.  Kidneys.  —  Right  kidney  contains  an  infarct  of  some  standing;  left  also. 
Spleen. — Very  large,  contains  two  large  infarcts.  Brain. — Brain  appears  firm  and 
healthy.  There  is  an  embolus  at  the  junction  of  middle  and  anterior  cerebral  arteries 
on  the  right  side  ;  there  has  evidently  been  embolism  of  one  of  the  branches  of  the  middle 
cerebral  of  the  left  side  in  the  Sylvian  fissure,  as  it  is  white  and  apparently  plugged. 
Making  horizontal  sections  through  the  brain,  the  first  section  shows  some  surface  soften- 
ing of  the  left  ascending  parietal  convolution.  Section  made  through  the  roof  of  the 
lateral  ventricle  shows  softening  of  the  convolutions  of  the  island  of  Reil  and  caudate 
nucleus.  Section  through  internal  capsule  shows  a  patch  of  softening  involving  the 
lenticular-striate  artery,  which  is  plugged  with  clot  and  impervious.  The  softened  parts  are 
of  a  rusty  colour.  The  hemiplegia  was  no  doubt  due  to  an  embolus  in  the  left  lenticular- 
striate  artery,  and  the  softening  on  the  surface  to  embolism  of  branch  of  left  middle 
cerebral  (see  fig.  iii). 

There  are  other  cases  of  acute  endocarditis,  however,  which  end  in  recovery  at  any 
rate  for  a  time.  We  have  seen  several  cases  where  there  has  been  pyrexia  of  an  inter- 
mittent type  for  many  months  gradually  improve,  and  finally  the  temperature  has  become 
normal,  and  they  have  been  able  to  get  about  and  appear  quite  well,  but  have  doubtless 
had  damaged  mitral  valves. 

Chronic  Heart  Bisease 

The  immediate  result  of  endocarditis  is  to  cause  a  swelling  and  roughness 
of  the  endocardium  which  prevents  the  complete  closure  of  the  valves  and 
thus  allows  of  regtirgitation  (see  fig.  79) ;  puckering  and  thickening  of  the 
valves  takes  place  as  time  goes  on,  especially  if  there  are  recurrent  attacks, 
and  the  valves  become  permanently  damaged.  In  children  it  is  the  mitral 
which  almost  constantly  suffers.  In  some  chronic  cases  the  valves  become 
adherent  at  their  edges,  and  thus  stenosis  is  produced.  Gradually  other 
and  compensatory  changes  take  place  ;  if  the  regurgitation  occurs  at  the 
mitral  orifice,  the  left  ventricle  gradually  dilates  and  becomes  hypertrophied. 
At  first  the  compensatory  changes  which  take  place  are  sufficient  to  prevent 
the  patient  from  feehng  any  inconvenience,  and  both  he  and  his  friends  may 
be  ignorant  of  the  existence  of  valvular  disease  ;  but  sooner  or  later  dyspnoea 
on  exertion  and  precordial  pain  are  complained  of,  which  direct  attention  to 
the  heart.  Such  patients  often  suffer  from  bronchitis — a  result  of  the  con- 
stant congestion  of  the  lungs  which  is  present  in  mitral  regurgitation.  If  a 
physical  examination  of  the  heart  is  made  at  this  period,  a  bruit  is  detected, 
heard  loudest  at  the  apex,  but  well  conducted  into  the  axilla  and  to  the 
angle  of  the  scapula  ;  the  click  of  the  pulmonary  valves  is  accentuated,  while 
the  aortic  sounds  are  weak.  The  apex  beat  is  diffused  and  situated  outside 
the  nipple  line,  the  cardiac  dulness  is  increased  to  the  left  and  frequently  also 
to  the  right,  as  the  right  ventricle  is  apt  to  be  dilated  on  account  of  the  con- 
gested state  of  the  lungs.  In  some  cases  the  heart  becomes  enormously 
enlarged,  so  that  the  area  of  cardiac  dulness  extends  from  nipple  to  nipple, 
and  the  apex  beat  occupies  perhaps  the  fifth,  sixth,  and  seventh  spaces  outside 
the  nipple  fine,  while  the  whole  of  the  precordial  region  is  bulged  forward 


Chronic  Heart  Disease 


411 


by  the  hypertrophied  heart.  Often  the  left  bronchus  is  pressed  upon  and  the 
lower  lobe  of  the  lung  becomes  collapsed.  During  the  last  stages,  which 
may  be  short  or  prolonged  intermittently  for  many  months  or  even  years, 
the  liver  becomes  congested  and  enlarged,  there  is  albuminuria  from  con- 
gested kidneys,  while  the  belly,  scrotum,  and  legs  become  dropsical. 
Attacks  of  dyspnoea  with  pain  resembling  angina  pectoris  are  not  un- 
common towards  the  last.  Such  cases  may  be  very  chronic,  and  even 
repeated  attacks  accompanied  by  much  orthopnoea,  cardiac  distress,  bron- 
chitis, and  dropsy  may  be  recovered  from  and  the  patient  once  more  be 
patched  up.  In  such  cases,  however,  probably  no  fresh  endocarditis  occurs, 
and    the   attack  is  due  more  to   the   engorged    state    of  the   lungs  and  a 


Fig.  79. — Acute  Endocarditis  of  Mitral  Valves  In  a  case  of  Chorea. 
(See  Fatal  Case  of  Chorea.) 


temporarily  overworked  heart,  the  latter  recovering  by  rest  in  bed,  and  the 
symptoms  disappearing  as  the  bronchitis  passes  off.  Should,  however,  peri- 
carditis occur  in  a  case  of  old-standing  heart  disease,  the  end  is  not  far  off, 
as  the  muscle  becomes  damaged  and  further  work  is  imposed  on  an  already 
burdened  heart. 

In  order  to  illustrate  the  lesions  most  commonly  found  in  chronic  heart 
disease  in  children,  we  have  analysed  the  results  of  forty- one  post-mortems 
made  at  the  Children's  Hospital,  Manchester,  during  the  last  few  years,  on 
patients  who  have  been  under  the  care  of  our  colleague  Dr.  Hutton  or  one 
of  ourselves.  The  youngest  was  three  years  and  eight  months  at  the  time 
of  death,  and  the  oldest  fourteen  years.      With  one  exception  all  died  from 


412  Diseases  of  the  Circulatory  System 

the  results  of  chronic  heart  disease — that  is,  the  heart  disease  was  primary, 
those  cases  dying  with  pericarditis  or  endocarditis  accompanying  septictemia 
or  other  fatal  disease  being  excluded.  They  may  be  divided  into  the  follow- 
ing groups  : 

1.  Maligrnant  '  ulcerative  '  endocarditis    with    embolisms 

in  various  organs.     Peiicarditis  mostly  absent         .         .       5  cases 

2.  Acute  pericarditis  occurring  in  a  heart  already  more  or 

less  dilated  from  the  effects  of  mitral  disease,  and 
perhaps  old  pericarditis.  Recent  endocarditis  mostly 
slight,  coincident  with  the  pericarditis     .         .         .         .20  cases 

3.  Adherent  pericardium. — Former  attacks  of  pericarditis 

which  had  given  rise  to  thick  leathery  adhesions  around 
the  heart,  and  in  connection  with  old  mitral  disease 
had  given  rise  to  extensive  dilatation  and  gradual  heart 
failure.  A  small  aorta  usually  present  and  dilated 
pulmonary  artery  ;  mostly  bronchitis  and  hypostatic 
congestion  of  the  lungs    .......     10  cases 

4.  Chronic     valvular     disease     -without     pericarditis. — 

Mitral  incompetency,  dilatation  of  both  ventricles, 
bronchitis  and  hypostatic  congestion  of  the  lungs .         .      6  cases 

In  the  above  forty-one  cases  the  pericardium  had  been  affected  thirty 
times  ;  in  the  remaining  eleven  no  inflammatory  lesion  of  the  pericardium 
had  taken  place,  but  clear  fluid  without  lymph  was  present  in  several  of 
these.  In  several  cases  of  acute  pericarditis  the  amount  of  fluid  was  ex- 
cessive, amounting  in  one  case  in  a  girl  of  nine  years  to  20  oz.,  the  heart 
with  the  distended  pericardium  measuring  6|  in.  from  right  to  left  ;  in 
another  the  pericardium  contained  14  oz.  In  other  cases  the  cavity  of  the 
pericardium  was  obliterated  by  old  adhesions  forming  a  thick  layer  one-eighth 
to  one-quarter  inch  thick,  which  had  evidently  played  an  important  part  in 
bringing  about  the  fatal  result. 

The  mitral  orifice  was  affected  in  every  case  ;  in  the  malignant  variety 
of  endocarditis  there  were  the  usual  luxuriant  vegetations  present,  mostly 
extending  along  the  posterior  wall  of  the  left  auricle  where  the  regurgitant 
stream  of  blood  had  imping"ed.  In  the  slighter  forms  of  endocarditis  the 
lines  of  contact  of  the  valves  were  simply  roughened,  having  lost  their  shiny 
surface.  In  other  cases  there  was  evidence  of  old  endocarditis,  the  edges 
of  the  flaps  were  thickened,  the  chords  tendinese  were  thick  and  short,  and 
in  one  case  several  chordse  had  ruptured.  As  a  result  of  this  and  also  of 
the  dilatation  of  the  ventricles,  the  mitral  orifice  was  incompetent,  the  valves 
not  meeting  during  systole,  or  if  coming  in  contact  the  roughened  surface 
allowing  blood  to  regurgitate  into  the  auricle.  In  only  two  cases  was  there 
any  stenosis  of  the  mitral  orifice,  mostly  the  orifice  admitted  two  fingers  side 
by  side,  or  it  was  wider  still.  In  one  of  the  cases  of  stenosis  the  mitral 
orifice  only  admitted  .one  finger,  the  boy  had  not  had  rheumatism  ;  he  died 
of  tubercular  pericarditis  and  peritonitis  (see  case,  p.  406).  In  the  other  case 
the  patient  was  a  boy  of  thirteen,  who  had  been  in  the  hospital  five  times 
with  chorea,  and  finally  with  chronic  lung  trouble.  At  Xki^  post  mortem  there 
were  caseation  and  small  cavities  in  the  lungs,  no  definite  tubercle  anywhere. 


Chronic  Heart  Disease  413 

a  puckered  and  funnel-shaped  mitral  orifice,  and  recent  and  old  endocarditis 
of  the  tricuspid  valves. 

The  aortic  valves  were  affected  in  twenty,  that  is,  in  about  half  the 
cases,  but  the  lesions  were  of  a  far  less  advanced  or  serious  nature  than  in 
the  case  of  the  mitral.  In  most  of  the  cases  the  valves  were  competent, 
and  in  no  case  had  regurgitation  apparently  occurred  to  any  great  extent. 
Six  times  the  note  was  made,  '  The  aorta  only  admits  the  little  finger  ; '  this 
was  due  not  to  the  effects  of  valvular  disease  but  to  undergrowth  in  the  aorta, 
which  has  already  been  referred  to. 

The  tricuspid  valves  were  affected  thirteen  times,  or  in  about  one-third  of 
the  cases,  either  by  recent  or  old  endocarditis.  Probably  the  tricuspid  valves 
were  incompetent  in  the  majority  of  cases  in  consequence  of  the  dilatation 
of  the  right  ventricle.  The  note  often  occurs  that  the  tricuspid  orifice  was 
abnormally  wide,  and  on  one  occasion  it  admitted  four  fingers  side  by  side. 

The  pulmonary  valves  in  two  cases  had  slight  vegetations  on  them 
along  the  lines  of  contact.  In  most  cases  the  pulmonai-y  artery  was  dilated 
from  the  effects  of  back  pressure. 

The  murmurs  heard  during  auscultation  in  the  case  of  children  are  in 
some  ways  more  puzzling  than  those  heard  in  adults.  This  is  due  in  part 
to  the  more  rapid  action  of  the  heart,  and  this  is  especially  the  case  in  trying 
to  time  a  murmur  present  in  the  case  of  congenital  heart  disease  in  an  infant. 
In  chronic  heart  disease  in  children  the  hearts  are  larger  and  occupy  more 
space  in  the  chest  as  compared  with  adults.  Exocardial  sounds  are  com- 
moner in  children,  and  may  be  mistaken  for  murmurs. 

In  acute  febrile  diseases  like  scarlet  fever  or  influenza,  a  murmurish  first 
sound  may  often  be  heard,  and  inasmuch  as  endocarditis  does  at  times 
occur  in  these  diseases,  we  may  at  times  be  in  doubt  as  to  whether  the 
abnormal  sound  is  due  to  endocarditis  or  not.  In  these  cases  even  an 
experienced  ear  may  be  deceived  and  an  endocarditis  is  suspected,  when 
the  sequel  proves  this  to  have  been  a  mistake.  The  bruit  may  disappear  as 
the  pulse  and  temperature  fall.  Certainly,  murmurish  first  sounds  are  heard 
during  scarlet  fever,  which  disappear  during  convalescence  ;  but,  on  the 
other  hand,  an  endocarditis  occurring  during  scarlet  fever  is  apt  to  be  over- 
looked. Iji  acute  rheumatism  or  chorea  a  slight  endocarditis  may  be  over- 
looked, inasmuch  as  it  may  not  give  rise  to  a  murmur,  the  tiny  swellings 
along  the  line  of  contact  of  the  valves  being  too  minute  to  allow  of  re- 
gurgitation, and  it  is  only  perhaps  after  some  weeks,  it  may  be  during  con- 
valescence, that  the  murmur  is  heard. 

Regurgitation  through  a  damaged  mitral  valve  gives  rise  to  a  murmur 
accompanying  or  replacing  the  first  sound  at  the  apex.  Post-viortem 
evidence  shows  that  if  heart  disease  exists,  there  is  regurgitation  through 
the  mitral  orifice  or  damage  to  the  mitral  valve  in  practically  all  the  cases, 
though  other  valves,  as  also  the  pericardium,  may  share  in  the  damage.  In 
the  vast  majority  of  cases  there  is  regurgitation  and  no  stenosis.  In  a  con- 
siderable proportion  of  cases  of  chronic  heart  disease  in  children,  especially 
where  there  is  a  dilatation  of  the  cavities,  there  is  a  double  or  treble 
murmur  at  the  apex,  there  being  either  a  presystolic  or  a  diastolic  in 
addition  to  the  mitral  systolic.  The  presystolic  is  generally  heard  as  a 
'  churning '  or  '  rumbling '  sound  preceding  the  systolic  bruit  and  running 


414  Diseases  of  the  Circulatory  System 

up  to  it.  Is  the  presystolic  under  these  circumstances  diagnostic  of  a 
contracted  mitral  ?  The  result  of  our  post-mortems  lend  no  support  to  this 
view.  In  the  two  cases  in  which  a  contracted  mitral  was  iouxid^post  mortem 
there  was  no  bruit  at  all  heard  during  life  in  one,  and  a  systolic  bruit  in  the 
other.  In  the  cases  in  which  a  presystolic  and  systolic  were  heard,  there 
was  no  stenosis  found  post  mortem,  but  in  one  case  ruptured  chordie,  and  in 
others  thickened  and  puckered  valves.  No  bruit  is  more  perplexing  than 
the  so-called  diastolic  mitral.  This  apex  diastoHc  is  common  enough  in 
the  later  stages  of  chronic  heart  disease  when  there  is  much  dilatation.  In 
some  cases  there  is  a  banging  or  intensified  second  sound  at  the  apex, 
produced  presumably  at  the  pulmonary  orifice,  and  perhaps  the  diastohc 
bruit  may  be  what  Dr.  G.  Steell  has  called  'the  murmur  of  high  pressure  in 
the  pulmonary  artery,'  which  is  well  conducted  to  the  apex.  It  can  hardly 
be  produced  at  the  aortic  orifice,  as  in  some  cases  where  it  has  been  heard 
the  aortic  valves  were  normal  and  could  not  have  allowed  of  regurgitation. 
We  have  noted  this  murmur  in  cases  in  which  the  pericardium  was  adherent 
and  incases  in  which  it  was  normal.  On  several  occasions  we  have  noted 
the  presence  of  a  diastolic  bruit,  and  on  a  later  occasion  have  described  it  as 
being  presystolic,  and  this  has  been  confirmed  by  others. 

Murmurs  produced  at  the  tricuspid  orifice  are  best  heard  at  the  tip  of 
the  sternum,  probably  they  are  often  masked  by  the  presence  of  a  loud 
mitral  murmur.  A  double  bruit  at  the  base  indicating  stenosis  and  re- 
gurgitation at  the  aortic  orifice  is  not  common  in  children,  though  a  systolic 
bruit  is  common  enough.  Often  the  mitral  systoHc  is  so  well  conducted  to 
the  base  that  a  doubt  may  be  raised  as  to  whether  there  is  aortic  stenosis 
or  not.  In  some  cases  in  which  a  double  bruit  has  been  best  heard  over 
the  pulmonary  area,  we  have  ioxm^  post-mortem  disease  of  the  aortic  valves, 
while  the  pulmonary  have  been  healthy.  , 

Bilatation  of  the  cavities  of  the  heart  takes  place  in  children  apart  from 
valvular  disease,  under  two  circumstances — an  excess  of  blood  pressure,  as  in 
acute  nephritis,  the  force  acting  from  within  and  bulging  the  heart  walls  as  it 
were  ;  a  chronic  pericarditis,  with  adherent  pericardium  interfering  with 
the  systole,  and  so  tending  to  dilatation,  or  a  carditis  wither  without  pericar- 
ditis damaging  the  cardiac  walls.  Acute  dilatation  of  all  the  cavities  rapidly 
takes  place  in  some  cases  of  acute  nephritis  following  scarlet  fever  ;  the 
apex  beat  becomes  diffused,  and  is  seen  outside  the  nipple  line  ;  in  a  few 
cases  there  is  a  bruit,  due  to  the  imperfect  closure  of  the  mitral  valves,  and 
symptoms  of  cardiac  failure,  and  perhaps  sudden  death  may  take  place. 
Dilatation  of  the  left  ventricle  may  occur  in  anaemia.  Dilatation  due  to 
chronic  pericarditis  is  a  cause  of  chronic  rather  than  acute  heart  disease  ;  a 
pure  case  of  this  is  rare,  as  endocarditis  mostly  occurs  also  ;  but  sometimes 
cases  may  be  found  in  which  the  heart  is  enlarged  and  the  cavities  dilated, 
with  a  thick  pericardial  attachment  outside  ;  the  valves  are  normal  or  perhaps 
more  or  less  thickened,  and  have  evidently  been  incompetent  during  life. 
In  these  cases,  as  already  pointed  out,  the  dilatation  has  probably  taken 
place  during  one  or  more  rheumatic  attacks.  We  have  noticed  signs  of 
dilated  heart  with  a  muffled  first  sound  in  growing  delicate  boys  towards 
puberty,  especially  if  they  are  given  to  violent  exercises. 


Chronic  Heart  Disease  415 

Acute  IVIyocarditls. — Acute  myocarditis,  apart  from  rheumatic  peri- 
carditis, is  not  a  common  affection  at  any  time  of  life,  and  much  difficulty 
exists  in  stating  what  it  consists  in,  as  any  general  acute  process  affecting 
the  heart  must  quickly  bring  a  fatal  issue.  Changes  in  the  cardiac  muscles 
of  a  coarse  description  do  occasionally  occur.  In  rare  cases  children  have 
been  attacked  with  an  acute  illness  with  fever  and  delirium,  and  at  the 
post-mortem  an  unsuspected  abscess  has  been  found  in  the  muscle  of  the 
heart ;  such  cases  are  probably  septictemic,  as  also  are  those  where  minute 
abscesses  are  found.  Acute  myocarditis  appears  also  to  occur  in  diphtheria  ; 
there  is  a  general  dilatation  of  the  heart,  more  or  less  local  pain,  and  dys- 
pnoea followed  by  a  fatal  issue,  changes  being  found  in  the  muscular  fibre  ot 
the  heart,  the  muscular  fibres  being  distended  with  fine  granules  of  fat 
obscuring  the  striae.  It  is  well  known,  however,  that  sudden  death  may 
occur  in  diphtheria  from  paresis  of  the  respiratory  muscles,  as  well  as  from 
disturbed  innervation  of  the  heart,  so  caution  is  recjuired  in  coming  to  a  con- 
clusion that  a  myocarditis  exists.  Steffen  has  described  a  form  of  local  myo- 
carditis occurring  in  the  course  of  typhoid,  accompanied  by  symptoms  of 
cardiac  failure  during  life.  Such  cases  must  be  rare.  Myocarditis  or  a 
degeneration  of  the  cardiac  muscle  may  accompany  both  pericarditis  and 
endocarditis.  Steffen  has  also  recorded  cases  of  myocarditis  with  dilatation 
in  some  cases  of  purpura. 

Prognosis. — Acute  pericarditis  or  carditis  occurring  in  association  with 
rheumatism  is  a  dangerous  affection,  especially  in  young  children.  The 
younger  the  child,  the  worse  is  the  prognosis.  A  rheumatic  pericarditis 
occurring  in  a  child  4  or  5  years  of  age  is  exceedingly  likely  to  end  fatally  or 
leave  behind  a  much  dilated  and  damaged  heart.  A  sudden  cardiac  syncope 
may  at  any  time  take  place.  In  less  acute  cases  of  pericarditis  or  pei'i- 
endocarditis,  especially  in  older  children,  the  immediate  danger  to  life  is  not 
great,  but  the  outlook  in  the  long  run  is  serious.  Pericarditis  occurring  in 
a  heart  which  is  hypertrophied  from  old-standing  valvular  disease  is  an  ex- 
ceedingly dangerous  and  fatal  affection,  and  generally  marks  the  beginning 
of  the  end.  Death  maybe  sudden  at  the  last.  In  endocarditis  occurring  in 
the  course  of  rheumatism  there  is,  of  course,  great  danger  that  permanent 
damage  may  be  inflicted  on  the  valves  and  the  patient  be  handicapped  for 
life.  On  the  other  hand,  there  is  abundant  evidence  to  show  that  bruits 
due  to  endocarditis,  occurring  either  in  connection  with  chorea  or  rheuma- 
tism, may  disappear,  and  there  is  no  reason  why  the  endocardium  may  not 
return  to  its  normal  condition  without  crippling  the  valves  ;  there  is, 
however,  the  constant  fear  of  a  fresh  attack  at  the  old  spot.  The  prognosis 
in  malignant  endocarditis  is  eminently  unfavourable,  though  cases  which 
apparently  belong  to  this  category  occasionally  recover.  In  chronic  heart 
disease  the  amount  of  hypertrophy  and  dilatation  present  may  be  taken  as 
an  index  of  the  damage  the  heart  has  suffered.  The  prognosis  in  dilated 
hearts  secondary  to  nephritis  is  favourable  if  the  nephritis  subsides  and  no 
valvular  disease  remains. 

TrcatnieJit. — The  treatment  of  pericarditis  and  that  of  endocarditis  have 
so  much  in  common  that  they  may  be  taken  together.  It  is  needless  to  in- 
sist that  the  child  should  be  put  to  bed  and  religiously  kept  quiet,  all  exertion 
and  excitement  being  zealously  guarded  against.    Too  much  stress  cannot  be 


4 [6  Diseases  of  the  Circulatory  System 

laid  upon  the  importance  of  this,  and  of  maintaining  rest  in  bed  long  after  the 
acute  symptoms  have  passed  away.  To  keep  the  heart  as  quiet  as  possible, 
and  to  impose  the  lightest  work  on  it,  during  and  after  the  attack,  are  points 
of  the  highest  moment.  The  diet  given  must  be  suited  to  the  rheumatic  state  ; 
if  peri-endocarditis  is  associated  with  it,  milk  and  fluids  will  form  the  prin- 
cipal part.  Of  the  local  treatment  during  the  acute  stage,  applications  which 
soothe  are  better  than  counter-irritants.  Ext.  of  belladonna  moistened  with 
glycerine  may  be  spread  on  lint  or  flannel,  and  applied  to  the  precordial 
region,  and  covered  with  a  layer  of  cotton  wool,  or  spongio-piline  wrung  out 
of  hot  water  and  sprinkled  with  laudanum  maybe  applied.  If  there  is  much 
pain,  a  light  mustard  poultice  (one  in  four  or  six)  kept  on  for  some  hours  so 
as  to  redden  the  skin  will  usually  relieve.  Lin.  aconiti  and  lin.  iodi,  equal 
parts,  may  be  painted  over  the  precordial  regions.  Local  blood-letting  by 
applying  one  or  two  leeches  over  the  sternum  is  often  useful  in  appropriate 
cases.  Dr.  D.  B.  Lees  has  highly  extolled  the  eff'ects  of  an  ice  bag  applied 
to  the  pericardial  region.  We  have  seen  cases  where  this  method  has  been 
useful,  but  some  patients  rebel  against  it.  Of  medicines,  sahcylate  of  soda, 
with  liq.  ammon.  acet.  if  the  inflammatory  lesion  is  dependent  on  the  rheu- 
matic state,  may  be  prescribed,  tinct.  digitahs  being  substituted  and  given 
in  3  to  5  minim  doses  every  four  hours  if  there  is  much  dyspnoea  or 
sign  of  cardiac  failure.  Small  doses  of  opium  are  usually  required,  and 
are  often  of  the  greatest  use  in  relieving  pain  and  quieting  the  heart's 
action.  Half  to  two  grains  of  Dover's  powder  may  be  given  at  night, 
and  repeated  once  or  twice  in  the  twenty-four  hours,  according  to 
circumstances.     (See  also  F.  75,  76,  77,  78,  81,  and  82.)     {Appe7idix.) 

In  pericardial  effusion,  if  extensive,  tapping  of  the  pericardium  may  have 
to  be  resorted  to,  to  relieve  the  pressure  on  the  heart.  Before  this  is  done 
as  accurate  a  diagnosis  as  possible  must  be  made,  to  ascertain  how  much 
the  symptoms  present,  dyspnoea,  orthopnoea,  and  cyanosis,  are  due  to  pres- 
sure of  fluid,  and  how  much  to  a  dilated  or  hypertrophied  heart ;  as  many, 
perhaps  most,  of  the  cases  of  children  with  which  we  have  to  deal  are  in 
reality  cases  of  pericarditis  supervening  on  chronic  heart  disease.  In  the 
latter  case,  if  there  is  much  cardiac  dilatation  and  comparatively  little  fluid, 
paracentesis  cannot  reUeve  to  any  extent,  and  the  cardiac  walls  may  be 
wounded,  though  if  3.  fine  exploring  needle  be  used  no  great  damage  can  be 
done.'  The  spot  selected  for  paracentesis  is  usually  the  fourth  or  fifth  inter- 
space, half  way  between  the  left  nipple  line  and  the  left  edge  of  the  sternum, 
but  care  should  be  used  to  ascertain  the  position  of  the  apex  beat  as  nearly 
as  possible.  Having  by  the  cautious  use  of  an  exploring  syringe  with  a  fine 
needle  ascertained  the  presence  of  fluid,  a  trochar  and  cannula  may  be  used 
to  draw    it   off,  care  being  taken  to  withdraw  the  trochar  as  soon  as  the 

1  On  one  occasion  we  tapped  the  pericardium  with  an  exploring  syringe  armed  with  a 
large  sharp-pointed  hollow  needle,  and  withdrew  some  two  ounces  of  serum  ;  this  was 
followed  by  pure  blood.  After  the  needle  was  withdrawn  the  child  became  rapidly  worse, 
and  died  in  a  few  minutes.  The  post-mortem  showed  the  pericardium  full  of  blood,  and  a 
puncture  wound  through  the  right  ventricular  wall  close  to  the  interventricular  septum. 
The  wall  was  very  thin  at  this  spot  and  almost  fibroid.  Had  a  trochar  and  cannula  been 
used,  the  trochar  being  withdrawn  on  entering  the  pericardium,  this  accident  could  not 
have  happened.  The  needle  had  entered  the  pericardial  sac  in  the  first  instance,  and  then 
entered  the  right  ventricle. 


Chronic  Heart  Disease  417 

cannula  is  well  inside  the  cavity  of  the  sac.  As  a  matter  of  fact  paracentesis 
pericardii  is  rarely  of  much  use,  though  it  may  postpone  the  fatal  result  a 
few  hours,  and  bring  temporary  relief 

In  chronic  pericardial  effusion  the  inunction  of  blue  ointment  or  counter- 
irritation  by  flying  blisters  may  be  tried.  In  chronic  purulent  effusion, 
aspiration  should  be  first  tried  ;  if  this  fail  to  prevent  reaccumulation, 
incision  and  drainage  by  an  india-rubber  tube  should  be  resorted  to  ;  this  is 
occasionally  successful,  as  in  the  case  recorded  by  Dr.  S.  West.  Symptoms 
of  cardiac  failure  should  be  treated  by  digitalis,  ammonia,  ether,  or  alcohol. 
Ether  may  be  injected  subcutaneously  or  a  few  drops  may  be  inhaled.  The 
treatment  of  malignant  or  ulcerative  endocarditis  is  unsatisfactory,  and  no 
drugs  appear  to  influence  its  course.  The  most  likely  to  be  useful  are 
quinine,  digitalis,  and  the  sulpho-carbolates.  The  treatment  of  congenital 
or  chronic  heart  disease  must  be  directed  to  saving  the  heart  all  unnecessary 
work  and  to  strengthening  it  as  much  as  possible.  Children  with  chronic 
heart  disease  need  to  be  guarded  most  carefully  against  the  effects  of  cold, 
as  bronchitis  is  easily  contracted  in  such,  and  a  little  bronchitis  adds 
materially  to  the  work  of  the  heart,  which  is,  perhaps,  at  best  labouring 
under  great  mechanical  disadvantages.  The  parents  and  friends  of  such 
children  must  be  cautioned  against  allowing  the  child  to  over-tire  itself;  it 
is  no  uncommon  thing  for  such  a  child  to  go  for  a  while  to  the  sea-side  or 
convalescent  home  and  come  back  worse,  for  the  simple  reason  that  it  has 
been  on  its  legs  all  day,  enjoying  the  novelty  of  its  newly  found  pleasures  ; 
whereas  a  moderate  amount  only  of  exercise,  insufficient  to  over-work  the 
heart,  would  have  secured  an  improvement.  All  active  exercise  should  be 
forbidden,  rough  games,  riding  '  cycles,'  and  gymnastics.  The  medicines 
of  most  use  to  control  and  regulate  the  cardiac  contractions  are  digitalis, 
belladonna,  iron,  and  strychnine.  Digitalis  is  of  the  greatest  value,  but  must 
not  be  too  continuously  given  ;  any  intermittency  in  the  beat  should  be  the 
signal  for  its  omission.  When  dropsy  sets  in,  digitalis  with  diuretics  like 
iodide  o  potassium,  acetate  of  potash,  and  squills  will  be  required.  (F.  79 
and  80.)  In  excessive  dropsy  Southey's  cannula;  may  be  used  with  advantage. 

■    Mediastino-perlcarditls,   Pleuro.pericarditis 

An  inflammation  of  the  serous  membrane  which  is  reflected  over  the 
anterior  edges  of  the  lungs  and  surrounds  the  pericardium  sometimes  takes 
place,  mostly  in  association  with  a  more  general  pleurisy  or  with  pericarditis. 
At  times  the  pleurisy  appears  to  be  local,  being  confined  to  the  serous  mem- 
brane covering  the  pericardium  and  lung  adjoining  it.  The  symptoms  of 
such  an  inflammation  are  necessarily  indefinite,  almost  the  only  definite  sign 
being  a  pleuro-pericardial  friction  sound — that  is,  a  rubbing  sound  which  is 
synchronous  with  the  cardiac  beats,  and  which  is  more  intense  during  inspira- 
tion as  the  lung  expands  and  its  edge  passes  in  front  of  the  heart.  The  rub 
may  disappear  entirely  during  expiration.  The  deeper  the  inspiration  the 
more  intense  the  friction  sound  becomes.  As  a  result  the  edge  of  the  lung 
becomes  adherent  to  the  pericardium,  the  space  between  the  two  becoming 
obliterated.  In  some  cases  a  subacute  or  chronic  inflammatory  process  goes 
on  in  the  mediastinum,  involving  the  serous  membranes,  connective  tissue, 

F.  E 


4i8 


Diseases  of  the  Circulatory  System 


and  perhaps  the  mediastinal  glands,  so  that  a  matting  of  all  the  parts  takes 
place,  the  edges  of  the  lungs,  pericardium,  and  great  vessels  being  firmly  bound 
together.  The  pericardium  may  be  adherent  to  the  walls  of  the  heart,  there 
may  be  extensive  pleuritic  adhesions  of  one  or  both  lungs,  and  the  adhesions 
in  some  cases  are  tough  and  firm  and  of  almost  cartilaginous  hardness. 

The  etiology  of  these  cases  is  uncertain.  Many  cases  are  associated  with 
chronic  tuberculosis  of  the  lung  or  with  caseous  mediastinal  glands  ;  in 
others  no  evidence  of  tubercle  can  be  found,  a  simple  chronic  inflammation 
of  the  connective  tissue  going  on,  ending  in  cicatrisation.  The  immediate 
result  of  this  process  is  to  hamper  the  action  of  the  heart,  preventing  its 


Fig.  80. —Chronic  Mediastino-pericarditis.  Boy  13  years  (see  case,  p.  419).  The  anterior 
edges  of  the  lungs  were  adherent  ;  in  front  there  were  indurated  adhesions  in  the  anterior 
mediastinum. 

complete  systole,  to  interfere  with  the  filling  of  the  lungs  during  inspiration, 
and  to  compress  the  large  veins  |  entering  the  chest.  The  liver  becomes 
constantly  engorged,  the  hepatic  system  of  veins  dilated,  and  a  perihepatitis 
results. 

Symptoms. — The  course  of  this  curious  affection  is  very  chronic.  In 
well-marked  cases  the  symptoms  are  those  which  are  likely  to  be  caused  by 
an  obstruction  to  the  flow  of  blood  into  the  chest.  Dyspnoea  on  exertion, 
cyanosis  of  the  face,  clubbing  of  the  fingers,  distension  of  the  veins  of  the 
neck,  chest,  and  abdomen  during  inspiration,  and,  later,  cedema  of  the  face, 
arms,  feet,  and  abdomen.     There  may  be  signs  of  pulmonary  tuberculosis 


Mediastino-pericarditis ,  P leuro-pericarditis  419 

The  'pulsus  paradoxus' — i.  e.  the  pulse  becoming  smaller  during  inspiration 
— may  be  present,  but  certainly  it  is  absent  in  some  cases.  In  other  cases 
the  most  marked  symptom  is  ascites,  with  an  enlarged  liver,  suggesting  a 
primary  cirrhosis  of  the  liver  ;  such  cases  are  exceedingly  chronic,  and  they 
improve  if  the  fluid  in  the  abdomen  is  removed  by  tapping,  and  will  go  on 
for  months  or  even  years  ;  gradually  the  portal  obstruction  becomes  greater 
and  the  patient  dies  of  exhaustion.  The  spleen  does  not  appear  to  enlarge 
in  these  cases  as  it  does  in  primary  cirrhosis  of  the  liver. 

The  following  case  may  be  taken  as  an  example  of  this  affection,  running 
an  acute  course  : 

Mediastinitis,  Ascites. — John  E. ,  aged  2  years.  Admitted  September  9,  1891. 
Mother  states  that  her  first  five  children  are  dead.  No  history  of  syphilis  ;  patient  had 
convulsions  at  six  months  of  age.  Last  May  he  had  a  cough  and  was  attended  by  a 
doctor.  A  month  later  his  abdomen  began  to  swell,  and  soon  after  his  feet ;  this  has 
gradually  increased.  On  admission  his  face  is  puffy,  the  abdomen  is  distended  with  fluid, 
his  legs  are  much  swollen.  Temperature  101°,  pulse  130,  respiration  40.  Lungs. — There 
is  some  diminished  resonance  over  the  right  upper  lobe  in  front ;  over  both  lungs  there 
are  fine  bubbling  rales.  Heart. — Ape.x  beat  in  third  interspace  sounds  normal.  Abdomen 
is  greatly  distended,  dulness  in  both  flanks  and  in  epigastrium,  thrill  plainly  felt.  Liver. — 
Edge  not  readily  felt,  spleen  cannot  be  felt.  September  10. — Temperature  is  103°,  varies 
from  99°  to  103^.  Crepitation  in  lungs  on  both  sides.  September  14.^ — Child  evidently 
dying  ;  abdomen  rela.xed  ;  edge  of  liver,  both  right  and  left  lobe,  felt  below  umbilicus  ;  a 
nodule  about  the  size  of  a  marble  felt  in  the  left  lobe.  Temperature  io5°-io6°  before 
death.  Post-mortem. — Lu?igs  not  adherent ;  right  lower  lobe  semi-solid  with  pneumonia  ; 
upper  lobe  of  left  solid  with  graines  jaiines,  but  no  tubercle.  Much  yellow  fluid  in 
abdomen  and  some  lymph  on  liver,  spleen,  diaphragm,  and  great  omentum.  Heart  not 
enlarged  ;  pericardium  thick  and  adherent,  but  can  be  peeled  off,  leaving  a  granular  sur- 
face adherent  to  the  diaphragm.  In  the  middle  and  posterior  mediastinum  there  are 
enlarged  glands  and  much  fibrous  tissue.  The  glands  are  enlarged  and  caseating,  one  the 
size  of  a  filbert,  several  with  putty-like  contents.  Abdomen. — I,ymph  and  tubercle  between 
liver  and  diaphragm,  some  lymph  on  surface  of  liver.  Liver  vaMch.  enlarged  and  granu- 
lar, one  boss  the  size  of  a  marble  on  the  anterior  surface  of  right  lobe  near  broad  ligament, 
creaks  when  cut  section  nutmeg  appearance.  Spleen  enlarged,  distended  with  blood. 
Kidneys  pale. 

Chronic  indurative  Mediastinitis. — James  R. ,  aged  13  years,  admitted  October  29,  1896. 
History  imperfect.  Mother  states  he  has  had  an  enlarged  abdomen  for  a  year,  which  she 
attributes  to  scarlet  fever.  When  admitted  the  boy  was  suffering  from  dyspnoea,  cyanosis, 
and  ascites.'  The  abdomen  was  tapped  and  251  oz.  of  fluid  removed.  An  examination 
of  the  chest  showed  dulness  at  both  bases  behind,  and  weak  breath  sounds,  much  dulness 
over  region  of  the  sternum,  the  heart's  impulse  could  not  be  seen  or  felt,  but  the  sounds, 
which  were  faint,  but  normal,  were  best  heard  just  outside  and  below  left  nipple  line  ; 
dulness  extends  §  in.  to  right  of  the  sternum.  Edge  of  liver  felt  25  in.  below  the  ribs, 
spleen  not  felt,  enlarged  veins  in  the  neck.  Pulse  diminishes  during  inspiration  on  both 
sides.  Much  relief  to  all  the  symptoms  by  tapping.  November  14. — Fluid  has  been 
re-accumulating,  d\'spnoea  urgent,  280  oz.  removed  by  tapping.  February  24. — Fluid  has 
been  slowly  accumulating,  boy  keeping  better  on  the  whole.  To-day  there  is  a  purpuric 
rash  on  body  and  limbs,  and  a  swelling,  apparently  a  periosteal  heemorrhage,  over  both 
forearms  (  ?  ulna).  February  26. — Synovitis  of  both  wrists  and  finger-joints,  and  also 
shoulder-joint,  with  temperature  of  99°-ioo°  F.  March  2. — Joints  better,  much  dyspnoea, 
friction  sounds  over  bases  of  lungs,  more  dulness  than  when  admitted.  Dyspnoea  urgent. 
Death  March  9.  Post-mortem. — Lungs. — Old  adhesions,  especially  right  along  the 
anterior  edges,  fixing  them  to  the  anterior  mediastinum,  bases  adherent  to  diaphragm, 
both  bases  behind  pleura  thickened  and  white,  resembling  '  porcelain  ;  '  the  thickened 
pleura  has  contracted  the  lungs.  Some  recent  pleurisy.  Section  tough  and  gorged  like 
'  heart '  lung.  Heart. — Much  fibroid  material  in  anterior  mediastinum  (fig.  80).  Pei-icardium 

E  E  2 


420  Diseases  of  the  Circulatory  System 

thickened  and  adherent  to  surrounding  parts,  adherent  to  heart  walls.  Heart  small,  wall 
thin,  no  dilatation,  no  endocarditis.  Muscle  easily  tears.  Aorta  admits  forefinger,  valves 
healthy.  Superior  vena  cava  dilated,  but  surrounded  and  fixed  by  indurated  tissues 
in  the  mediastinum.  Perito7ieum. — Much  ascites,  no  lymph.  Liver  capsule  thickened, 
adherent  to  diaphragm,  but  can  be  separated.  Capsule  looks  like  '  porcelain,'  with  a 
number  of  holes  through  it  showing  liver  surface.  Section  of  liver  shows  the  thickened 
capsule  has  rounded  off  the  edges  of  the  liver,  tying  it  up  into  a  ball.  Hepatic  veins 
dilated,  section  like  '  nutmeg,'  no  cirrhosis.  Spleen  enlarged,  capsule  thickened  and 
'  porcelain  '-like.     Kidneys  normal.     No  tubercular  disease  an}rvvhere. 

Raynaud's  Disease — Paroxysmal  Hsemog'Iobinuria 

About  one-fourth  of  the  cases  of  Raynaud's  disease  reported  occurred  in 
children  under  ten  years  of  age  (J.  E.  Morgan).  Concerning  the  etiology  of 
this  disease  nothing  is  known ;  in  some  cases  there  is  a  history  of  malaria, 
but  certainly  in  many  of  the  reported  cases  there  was  no  such  connection. 
In  some  cases  hemoglobinuria  has  been  a  prominent  symptom,  and  it  is 
believed  by  some  (Dickenson,  Abercrombie)  that  paroxysmal  heemoglobinuria 
is  a  part  of  the  more  general  disorder  which  may  or  may  not  be  present. 

The  first  symptoms  of  Raynaud's  disease  may  appear  as  early  as  the  end 
of  the  second  year,  the  friends  noticing  that  the  child's  hands  or  feet  after 
exposure  to  cold  become  numb  and  blue  ;  the  ears  and  cheeks  may  become 
easily  affected.  Before  an  attack  comes  on,  there  is  shivering  and  perhaps 
crying  with  pain  or  discomfort.  In  more  severe  cases  the  hands  and  feet  are 
swollen  and  of  a  dark-blue  colour.  In  some  of  the  cases  after  the  attack  is 
over  the  child  passes  urine  containing  albumen  and  haemoglobin  (J.  Aber- 
crombie). In  other  cases  no  abnormal  urine  is  noted.  The  exciting  cause 
of  the  attack  in  all  these  cases  is  exposure  to  cold  ;  the  attacks  are  commoner 
in  the  winter,  and  when  occurring  in  the  summer  the  attacks  follow  a  cold 
bath  or  a  chill  of  some  sort.  In  mild  cases  the  attack  does  not  last  long  ;  if 
warmth  is  applied  the  blueness  and  numbness  pass  off  in  the  course  of  half 
an  hour  or  less. 

While  such  is  the  common  type  of  attack  in  Raynaud's  disease,  it  happens 
at  times  that  the  numbness  or  blueness  of  the  extremities  ends  in  gangrene 
and  spontaneous  amputation.  A  typical  case  of  this  kind  is  recorded  by 
Harold  {Lancet^  February  9,  1895)  of  a  weakly  boy  of  four  years  of  age  ;  both 
hands  and  feet  were  affected.  The  hands  and  feet  were  blue  and  numbed,  the 
hands  recovered,  but  the  feet  beginning  at  the  toes  became  gangrenous,  and 
a  spontaneous  amputation  of  both  feet  gradually  occurred.  The  boy  eventu- 
ally made  a  good  recovery.  In  these  cases  there  is  no  doubt  a  stenosis  or 
narrowing  of  the  arteries  to  the  limb  or  the  capillary  arteries  are  affected. 
All  children  who  are  liable  to  these  attacks  obviously  require  the  greatest 
care  in  the  avoidance  of  cold,  and  possibly  during  cold  weather  have  to  be 
confined  to  bed,  or  at  any  rate  to  one  room.  The  treatment  is  the  treatment 
of  symptoms. 


42  1 


CHAPTER  XIX 

DISEASES    OF    THE    CIRCULATORY   SYSTEM — Continued 

irsevus. — Na2vus  is  perhaps  the  commonest  congenital  disfigurement 
met  with  in  children  ; '  usually  it  is  nothing  more  than  a  blemish,  though 
occasionally  it  becomes  more  serious,  either  from  danger  to  life  or  serious 
interference  with  its  subject's  welfare.  Nsevi  are  probably  always  congenital, 
though  not  always  noticed  at  birth,  since  they  may  not  be  large  enough  to 
be  conspicuous  until  some  time  later. 

Ntevi  belong  to  the  class  of  the  angiomata,  and  are  defined  as  'tumours 
consisting  of  newly  formed  blood-vessels,'  though  it  is  obvious  that  they  ai'e 
not  always  tumours  in  the  sense  of  their  being  any  definite  mass  of  tissue — 
e.g.  '  port-wine  stains ; '  still  this  is  merely  a  question  of  a  diffuse  as  con- 
trasted with  a  circumscribed  growth. 

These  growths  may  be  classified  as — 

I.  (a)  Simple  angioma^  telangiectasis,  congenital  nsevus,  mother's  mark  or 
port-wine  stain.  The  vessels  composing  the  new  formation  are  identical  in 
structure  with  normal  arteries,  veins  and  capillaries,  (b)  Cavernous  angioma^ 
lacunar  or  erectile  angioma.  The  blood  circulates  in  a  lacunar  system  as  in 
normal  erectile  tissue.     (Cornil  and  Ranvier.) 

II.  Na;vi  may  be  considered  as  (i)  arterial,  (2)  venous,  (3)  capillary, 
(4)  lacunar,  blood-vascular  growths. 

III.  Or,  considered  from  their  locality,  the  ngevi  may  be  divided  into 
(i)  cutaneous  :  (a)  a  mere  staining  or  port-wine  mark,  (b)  a  distinct  mass 
with  larger  vessels.  (2)  Subcutaneous.  (3)  Mixed — i.e.  both  cutaneous  and 
subcutaneous.     The  different  forms  of  njevi  are  readily  distinguishable. 

Stellate  ITsevus. — The  so-called  '  stellate  '  or  '  spider'  naevus,  which  is 
doubtfully  a  new  formation,  and  very  probably  only  a  dilatation  of  pre- 
existing vessels,  resembles  in  appearance  the  vense  stellatae  on  the  surface 
of  the  kidney  of  a  carnivore.  It  is  most  common  in  the  face,  chsappears  on 
pressure,  and  is  closely  allied  to  the  mere  weather  marks  of  those  exposed 
to  wind  and  cold  ;  it  is  sometimes  seen  about  the  faces  of  children. 

Port-wine  marks  consists  of  a  diffuse  stain,  varying  much  in  size,  form, 
position  and  colour  ;  usually  there  are  no  obvious  dilated  vessels,  though  these 
can  be  made  out  on  more  minute  examination.     These  marks  occur,  perhaps 

1  Depaul  is  quoted  by  Cornil  and  Ranvier  as  saying  that  one-third  of  the  children 
born  at  the  Clinic  of  the  Faculty  of  Medicine  in  Paris  have  nasvi,  and  these  mostly  dis- 
appear spontaneously  during  the  first  few  months  of  life. 


422 


Diseases  of  the  Circulatory  System 


most  commonly  on  the  face,  often  on  the  hands,  and  occasionally  else- 
where ;  they  may  cover  very  large  surfaces,  such  as  the  whole  side  of  the 
face.  There  is  no  elevation  of  the  growth  above  the  level  of  the  skin,  only 
the  superficial  layers  of  which  are  involved,  and  pressure  completely  obli- 
terates the  stain  for  the  time. 

Cutaneous  ITsevus. — The  common  cutaneous  nsevus  is  usuall}'  small, 
not  covering  more  than  a  square  inch  of  surface  at  most ;  it  is  somewhat 
raised  above  the  level  of  the  surrounding  skin  ;  the  individual  vessels  can 
often  be  distinctly  made  out,  though  not  always  ;  the  colour  of  the  growth  is 
usually  vivid  red,  and  on  pressure  the  colour  and  much  of  the  swelling  dis- 
appear, but  a  slight  thickening  remains  and  the  skin  is  '  granular.'^     These 

growths  lie  in  the  corium,  and  are 
usually  sharply  defined,  but  not  en- 
capsuled. 

Subcutaneous  Nsevus. — The 
growth  lies  entirely  beneath  the  co- 
rium, and  forms  a  distinct  tumour  ; 
the  skin  over  it  is  natural  in  colour, 
or  only  shows  a  faint  bluish  tint ;  the 
swelling  does  not  entirely  disappear 
on  pressure,  and  is  often  encapsuled 
more  or  less  perfectly." 

Mixed  Naevus. — This  is  a  com- 
moner form  than  the  last  ;  it  has  the 
characteristics  of  the  cutaneous  and 
subcutaneous  varieties  combined — 
i.e.  there  is  a  subcutaneous  naevus 
with  a  cutaneous  patch  on  its  sur- 
face ;  corium  and  subcutaneous  tis- 
sue are  both  involved.  It  is  seldom 
that  the  cutaneous  part  is  as  exten- 
sive as  the  subcutaneous,  and  in  this 
and  the  last  form  there  is  often  some 
cavernous  formation. 

After  removal  frorn  the  body  and 
escape  of  its  blood,  a  subcutaneous  or  mixed  nsevus  consists  of  a  tough, 
spongy,  or  stringy  mass,  often  somewhat  lobulated,  and  always  much  smaller 
than  might  be  expected  from  its  size  before  removal.  If  encapsuled,  it  will 
be  found  that  only  a  small  number  of  vessels,  and  those  of  considerable  size, 
feed  the  growth  and  enter  it  at  various  parts — a  very  important  fact  as  regards 
the  treatment  of  these  cases. 

Simple  xueevi  consist  of  newly  formed  vessels  having  the  structure  of 
capillaries,  and  presenting  ampullar  or  cirsoid  dilatations  ;  the  vessels  are 
supported  by  a  framework  of  connective  tissue,  and  often  fat. 

Cavernous  Waevi  consist  of  an  irregular  network  of  fibrous  tissue,  in- 
closing freely  intercommunicating  spaces  like  the  channels  in  a  sponge  ;  there 

1  Sir  J.  Paget. 

2  A  good  account  of  the  structure  of  nsevi  will  be  found  in  Cornil  and  Ranvier's 
Histology,  to  which  we  are  indebted  for  part  of  our  description. 


Fig.  8i. — Extensive  '  Mixed  '  Naevus  of  the  Face, 
involving  the  lower  lip  and  both  cheeks  up  to 
the  ears. 


N<2VUS 


423 


is  occasionally  unstriped  muscular  fibre  developed  in  the  septa,  as  well  as 
vessels  and  nerves.  The  endothelium  lining  a  n^rvoid  lacuna  is  exactly  like 
that  of  a  vein.  These  naevi  are  formed  by  dilatation  of  newly  developed 
capillaries  and  subsecjuent  absorption  of  their  barrier  walls,  so  that  free 
openings  are  made  between  adjacent  vessels. 

hnportance  of  NcEvi. —  Usually  nasvi  are  simply  disfigurements  ;  some- 
times, however,  they  may  give  rise  to  serious  bleeding  from  rupture  of  vessels 
by  injury  or  ulceration,  as  in  a  case  of  our  own  where  the  soft  palate  and 
uvula  were  the  seat  of  a  large  nevoid  growth  and  frequent  bleeding  occurred  ; 
similar  trouble  has  been  met  with  in  the  case  of  rectal  nasvi.  Internal  naivi 
may  possibly  be  dangerous  from  hcemorrhage,  or  from  extravasation  of  blood 
setting  up  peritonitis,  &c.  ;  but 
this  must  be  very  rare.  Some 
very  extensive  ntevi  are  of  im- 
portance from  interference  with 
the  action  of  the  muscles  or  the 
growth  of  bones,  or  from  pro- 
ducing" unwieldy  hypertrophy  of 
skin.  We  have  seen  fracture 
of  the  thigh  due  to  weakening 
of  the  femur  from  an  extensive 
naevus  growth  in  the  limb.^  Un- 
wieldy overgrowth  of  limbs  may 
occur  also  from  the  presence  of 
ntevi  ;  and  in  the  case  figured 
(fig.  82)  the  man  was  unable  to 
obtain  work  on  account  of  his 
disfigurement.  We  have  seen  a 
case  of  pyaemia  having  its  origin 
in  a  suppurating  naevus,  and 
another  where  pyeemia  followed 
puncture  and  partial  removal  of 
a  naevoid  growth. 

Changes  ocairrifig  ht  Ncevi. 
Nsevi  sometimes  grow  rapidly 
from  the  first  and  spread  over  considerable  areas  ;  in  many  cases,  however, 
they  grow  very  slowly,  alternately  grow  and  remain  stationary,  or  disappear 
altogether,  the  last  result  being  especially  common  in  the  cutaneous  form. 
As  Mr.  Holmes  and  others  have  pointed  out,  and  as  we  ourselves  have  seen, 
an  illness,  especially  apparently  whooping"  cough,  often  seems  to  bring  about 
the  cure  of  a  naevus  ;  possibly  the  straining  in  coughing  may  produce  extra- 
vasation and  thrombosis  in  the  neevus,  and  so  obliteration. 

Nsvi  undergo  spontaneous  cure  by  fibroid  change,  the  vessels  becoming 
obliterated  and  shrinking"  into  fibrous  cords.  Such  result  may  follow  treat- 
ment or  accidental  irritation  by  friction  of  the  clothes,  or  pressure  in  lying, 
and  so  on.  In  other  instances  calcareous  degeneration  or  thrombosis  takes 
place.     Cystic  change  in  naevi  is  very  common  ;    the  cysts  contain  serum, 

1  The  patient  was  under  the  care  of  our  colleague,  Mr.  T.  Jones. 


Fig.  82. — Nsevus  of  the  face  in  a  man  of  50.  The 
growth  was  steadily  but  slowly  increasing.  The  whole 
skin  of  that  side  of  the  face  was  deep  crimson,  the  lip 
and  tongue  were  involved,  and  the  lower  jaw  distorted 
and  everted  by  the  weight  of  the  enormous  lower  lip. 
The  man  died  of  aortic  aneurism.  The  specimen  is 
in  the  Owens  College  Museum. 


424  Diseases  of  the  Circulatory  System 

more  or  less  deeply  coloured,  and  arise  from  the  shutting  off  of  a  lacunar 
space  or  dilated  vessel  from  the  blood  stream  ;  the  cj-stic  is  often  combined 
with  the  fibrous  and  fatty  degeneration. 

Suppuration  and  ulceration  of  a  nasvus  is  an  important  condition  ;  for, 
on  the  one  hand,  it  may  produce  a  cure  by  obliteration  of  the  vessels,  or,  on 
the  other  hand,  as  already  pointed  out,  septic  absorption  or  bleeding  may 
result  :  happily  obliteration  is  the  common  termination.  \"arious  combina- 
tions of  these  changes  may  be  found  going  on  in  a  njevus  at  the  same  time  ; 
pigmentar\-  changes  are  also  found,  and  sometimes  an  overgrowth  of  hair, 
especially  in  the  lipomatous  form  {\'ide  p.  428).  Mere  pigmentary  maculae 
are  sometimes  called  ntevi,  but  it  is  better  to  restrict  the  name  to  the  vascular 
growtlii 

Sites  of  NcBvi. — Xsevi  may  be  found  almost  anywhere  over  the  body,  but 
there  are  certain  markedly  favourite  positions.  External  n£evi  are  most 
common  on  the  head,  and  of  all  places  we  should  say  the  most  frequent  is 
over  the  anterior  fontanelle  ;  the  lips,  nose,  cheeks,  eyelids,  or  any  part  of  the 
face  may  be  involved.  The  trunk  and  limbs  are  less  commonly  affected 
than  the  face,  but  perhaps  this  is  partly  to  be  accounted  for  by  the  mothers 
being  less  anxious  about  naevi  on  the  body  :  the  labia  are  not  uncommonly 
affected.  We  have  seen  a  case  in  which  most  alarming  growth  of  the  nsevus 
took  place  during  pregnancy  ;  subsidence  of  the  swelling  followed  delivery. 
Different  forms  of  neevi  often  occur  in  the  same  patient — e.g.  a  poit-wine 
mark  on  the  face  or  hand  and  a  mixed  nasvus  on  the  scalp.  Nce\"i  occurring 
inside  the  mouth,  in  the  cheeks,  tongue,  or  inner  surface  of  the  lip,  more 
rarely  in  the  palate,  are  of  course  more  serious  than  external  ones  ;  they  are 
also  much  less  common. 

Visceral  iiS.\-\  are  often  seen  on  the  liver,  and  less  often  on  the  kidneys, 
spleen,  and  other  organs  ;  the  muscles  and  bones  are  also  sometimes  affected. 
It  is  common  to  see  naevi  on  the  skin  of  meningoceles  both  cerebral  and 
spinal — a  fact  noticed  by  Mr.  Holmes,  and  one  of  some  importance  from  a 
diagnostic  point  of  \dew. 

Several  cases  of  rectal  n^vi  are  on  record,  among  others  one  mentioned 
by  Mr.  Barker  which  caused  death  b)^  haemorrhage.^  We  have  met  with  a 
case  which  exactly  simulated  piles,  and  was  cured  by  ligature.  The  extent 
of  tissue  involved  is  sometimes  very  great,  as  already  stated  ;  thus  we  have 
seen  the  whole  lower  extremity  n^evoid,  and  ]\Ir.  Barker  has  recorded  a  case 
of  the  whole  upper  extremity  being  so  affected-  {vide  also  fig.  82). 

TreatDient  of  Ncevi. — It  should  be  a  rule  of  practice  not  to  interfere  with 
nsvi  unless  they  are  growing  or  have  been  stationary  for  some  time,  since, 
as  already  pointed  out,  ver\-  many  disappear  of  themselves.  The  important 
points  to  consider  for  each  nsevus  are  whether  it  is  cutaneous,  subcutaneous, 
or  mixed,  and  what  is  its  relation  to  important  adjacent  structures,  which 
may  be  endangered  by  treatment  or  by  the  resulting  scar,  It  is  unnecessary 
to  mention  all  the  methods  proposed  for  treating  these  growiihs  ;  only  the 
most  efficient  will  be  described  here.  Stellate  naevi  may  readily  be  cured 
by  puncturing  the  centre  of  the  star  with  a  hot  needle.  Port-wine  marks 
require  careful  consideration  as  to  whether  the  resulting  white  scar  will  not 
be  as  disfiguring  as  the  red  mark,  and  it  must  be  remembered  that  in  cases 
1  Brit.  Med.  Jour.  1883.  -  Clin.  Soc.   Trans.  1884. 


Ncevus  ,  425 

where  a  large  surface  is  involved  a  long  course  of  treatment  is  required  to 
remove  the  mark. 

Linear  scarification,  multiple  puncture,  the  actual  cautery  or  a  caustic 
such  as  fuming  nitric  acid,  and  in  some  cases  electrolysis,  will  succeed. 
From  five  to  twenty  or  more  cells  of  a  Stohrer's  or  Weiss'  battery  should  be 
used  If  large,  the  patch  should  be  treated  in  sections,  so  as  not  to  have  too 
large  a  sore  surface  at  once. 

Cutaneous  nana  are  best  treated  with  the  actual  cautery  ;  ifsmall,  a  heated 
needle  is  sufficient  ;  in  larger  growths  Paquelin's  cautery  is  the  most  useful 
instrument.  Narrow  lines  may  be  scored  across  and  across  the  njevois,  or 
multiple  punctures  employed  ;  after  using  the  cautery  once,  as  soon  as  the 
wound  is  healed,  it  will  often  be  found  that  little  patches  remain  unoblite- 
rated  :  these  should  be  watched  for  some  weeks  before  reapplying  the  cautery, 
as  they  often  shrink  subsequently  without  further  operation.  The  cautery 
should  be  at  a  dull  red  heat,  and  should  be  applied  deeply  enough  to  reach 
through  the  navus.  Ethylate  of  sodium  is  fairly  efficient,  but  usually  requires 
several  applications,  and  is  not,  we  think,  better  than  the  cauteiy  ;  it  has  the 
advantage  of  not  requiring  the  use  of  an  anesthetic,  though  it  is  followed  by 
a  good  deal  of  temporary  smarting.  For  port-wine  stains  the  ethylate  may 
be  applied  every  two  or  three  days  according  to  the  effect  produced,  and 
then,  if  required,  fresh  applications  may  be  made  after  two  or  three  weeks. 
Vaccination  on  a  naevus  is  not  a  good  plan.  For  subcutaneous  or  mixed 
n£evi  we  cannot  recommend  injections  of  any  kind  ;  they  are  often  efficient, 
but  always  dangerous,  extensive  thrombosis  or  embolism,  causing  immediate 
death,  having  followed  their  use  ;  if  they  are  employed,  a  temporary  ligature 
should  be  put  round  the  naevus  and  removed  a  few  minutes  after  injection. 
Ligature  of  na;vi  is  uncertain,  as  well  as  tedious  and  troublesome.  We  think 
treatment  by  excision,  by  multiple  puncture  with  the  cautery,  and  in  suitable 
cases  by  electrolysis,  are  the  most  generally  useful  methods. 

Excision  is  applicable  to  well-encapsuled  growths  of  small  or  moderate 
size,  not  involving  important  structures.  There  are  certain  essential  points 
in  the  operation  :  first,  the  incisions  must  be  carried  well  wide  of  the  growth 
and  not  within  its  capsule  ;  there  will  then  be  only  a  few  well-defined  vessels 
to  secure,  arid  not  a  freely  bleeding  cavernous  tissue,  as  is  the  case  if  the 
growth  is  cut  into  ;  next,  the  skin  in  a  mixed  nsevus,  if  the  cutaneous  part 
is  veiy  small,  should  be  removed  as  far  as  it  is  involved,  provided  always 
the  edges  of  the  wound  can  afterwards  be  brought  together  easily  so  as  to 
obtain  primary  union.  If  the  skin  is  widely  involved,  it  should  not  be  taken 
away,  but,  as  suggested  by  Mr.  Teale,  dissected  off  the  naevus  and  pre- 
ser\-ed  ;  this,  however,  necessitates  opening  up  the  njevoid  tissue,  and  com- 
plicates the  operation  ;  sometimes  also  the  cutaneous  nsevus  continues  to  grow 
afterwards. 

A  bloodless  method  of  excising  ntevi  is  that  of  passing  long  needles  or 
harelip  pins  beneath  the  base  of  the  growth  crosswise,  then  winding  an 
elastic  thread  round  the  needles  and  excising  the  growth  after  dissecting  back 
skin  flaps  ;  the  needles  are  then  withdrawn  and  the  vessels  are  secured. 
There  is  no  bleeding  until  the  elastic  is  removed.^  Degenerated  naevi  should 
nearly  always  be  excised  if  they  are  treated  at  all  ;  in  some  instances,  where 
1  A  plan  devised,  we  believe,  by  Mr.  Davies  Colley. 


426 


Diseases  of  the  Circulatory  System 


there  is  cystic  degeneration,  a  seton  passed  through  the  cyst  causes  it  to 
shrink  ;  but  there  is  a  certain  amount  of  danger  in  this  plan  if  any  part  of  the 
nsvus  remains  undegenerated. 

The  httle  galvano-caustic  apparatus  devised  by  Mr.  Golding-Bird  for 
enucleating  lymphatic  glands  we  have  used  with  good  effect  for  large  mixed 
ncevi  not  removable  by  excision. 

In  using  the  actual  cautery  the  fine  or  middle-sized  point  of  the  Paquelin's 
cautery  is  entered  through  the  skin  and  made  to  traverse  the  nsvus  in 
several  directions  from  one  puncture  ;  if  the  nsevus  is  large,  this  is  repeated 

at  another  spot,  and  so  on  ;  a 
little  boric  acid  ointment  is  then 
applied  to  the  cauterised  surface 
and  the  effect  is  watched  ;  after 
all  contraction  has  ceased  another 
portion  is,  if  necessary,  attacked, 
until  the  whole  mass  has  shrunk. 
Pressure  is  occasionally  suc- 
cessful as  a  means  of  treating 
nsevi,  but  is  chiefly  applicable 
to  cases  where  other  treatment 
is  impracticable,  as  in  very  ex- 
tensive nsvus  of  a  limb  ;  ^  it 
may  be  employed  successfully 
sometimes  in  nasvus  of  the  scalp, 
where  the  underlying  skull  forms 
a  firm  basis  ;  especially  if  com- 
bined with  subcutaneous  break- 
ing up  of  the  naevus  with  a 
tenotome.  In  cases  of  ulcera- 
tion of  nsevi,  and  in  some  severe 
cutaneous  forms,  scraping  away 
the  growth  with  a  sharp  spoon 
will  sometimes  do  good. 
Importance  of  Ncevi  in  special  Localities. — Nsevi  occurring  in  certain 
localities  have  more  than  ordinary  importance,  either  from  the  difficulty  of 
their  treatment  or  diagnosis  or  from  the  risk  attaching  to  them.  Nasvus  of 
the  lip  is  often  found  involving  the  whole  thickness  of  either  lip,  and  is 
usually  either  of  the  mixed  or  subcutaneous  variety ;  the  surface  is  some- 
what prone  to  ulceration  in  the  mixed  form  from  constant  irritation,  and 
the  growth  is  often  very  unsightly.  If  degenerated  and  cystic,  or  if  there 
are  large  cavernous  spaces  in  the  naevus,  it  may  be  mistaken  for  a  labial 
mucous  cyst  or  for  lymphatic  macrocheilia.  Puncture  from  the  mucous 
aspect  with  the  Paquelin's  cautery  is  usually  the  best  mode  of  treatment, 
but  in  some  cases  it  is  a  good  plan  to  excise  a  segment  of  the  lip  and 
bring  the  edges  together  as  after  a  harelip  operation.  Orbital  nsevi  are 
usually  associated  with  similar  growths  upon  the  face  :  they  may  cause  ex- 
ophthalmos and  ectropion  ;  the  nsevoid  character  of  the  growth  is  indicated 

1  A  good  case  of  the  effects  of  pressure  under  such  circumstances  is  recorded  by  Hardie, 
Lancet,  May  1885. 


Fig.  83. — Orbital  Naevus.  The  growth  extended  deeply, 
causing  exophthalmos  and  ectropion,  and  spread  up- 
wards upon  the  forehead. 


Ncevus 


427 


by  the  spongy  feeling  and  the  possibility  in  some  cases  of  pushing  back 
the  protruding  eyeball  and  so  emptying  the  growth  of  blood.  Treatment  by 
electrolysis  is  the  only  serviceable  method  in  these  cases. 

Ntevus  of  the  tongue  may  give  rise  to  macroglossia  and  cause  protrusion 
of  the  organ,  or  may  be  limited  to  a  small  part  of  its  surface  ;  it  is  liable  to  be 
mistaken  for  lymphatic  macroglossia  or  for  a  mucous  cyst.  The  colour  will 
usually  serve  to  distinguish  it  from  the  former,  though  the  two  conditions 
seem  to  be  sometimes  combined,  and  the  compressibility  of  a  ntevus  will 
mark  it  off  from  the  latter  affection  ;  in  doubtful  cases  a  grooved  needle  will 
clear  up  the  difficulty.  The  actual  cautery,  or  in  rare  cases  excision,  of  a 
part  of  the  tongue  is  the  treatment  recjuired.  In  one  child  we  excised  the 
anterior  third  of  the  tongue  by  a  y\-shaped  incision,  and  brought  the  sides 
of  the  wedge  together  with  sutures  ;  the  result 
was  good  and  repair  vv'as  rapid.  A  similar 
condition  may  be  met  with  on  the  gums  or  inner 
surface  of  the  cheeks.  Sometimes  large  blood 
lacunae  are  met  with  beneath  the  tongue,  look- 
ing like  ranula  ;  the  soft  palate  and  uvula  are 
also  occasionally  affected  ;  in  one  instance 
where  both  conditions  existed  the  sublingual 
naevus  was  cured  by  the  actual  cautery,  and  the 
uvula  removed  by  the  galvanic  ecraseur  ;  the 
pati'fent  was  attacked  by  pycemia,  but  ultimately 
recovered  completely. 

Ncevus  of  the  eyelids  must  be  treated  with 
great  caution  to  prevent  any  subsequent  distor- 
tion ;  it  is  best  usually  to  attack  small  portions 
at  a  time  with  the  actual  cautery  and  wait  until 
cicatrisation  is  complete  before  a  second  application, 
to  nasvus  of  the  nose,  where  too  vigorous  treatment  may  produce  an  unsightly 
sharp-pointed,  beak-like  appearance  if  the  skin  is  too  much  destroyed.  In 
some  instances  excision  is  the  better  plan. 

Ncevi  around  the  orbit  are  sometimes  very  difficult  to  diagnose,  especially 
if  they  are  degenerated,  and  consequently  have  lost  their  colour  ;  dermoid 
cysts,  meningoceles,  simple  serous  congenital  cysts,  and  fatty  growths  should 
be  borne  in  mind  as  sources  of  fallacy.  In  one  instance  (fig.  83)  there  was  a 
cyst  with  none  of  the  appearance  of  a  nasvus  ;  on  tapping  it,  altered  blood 
escaped,  and  on  incision  it  was  found  that  the  growth  was  loculated  and  in 
part  solid  (i.e.  degenerated).  A  seton  was  passed  through  it  at  last  after 
failure  of  incision  and  drainage,  excision  being  out  of  the  question,  and  the 
mass  suppurated  freely,  but  unfortunately  erysipelas  occurred  and  the  child 
died.  At  the  post-morteiii  the  orbit  and  cavernous  sinus  were  found  full  of 
more  or  less  degenerated  nsevoid  tissue  ;  the  neevus  spaces  were  mostly  full 
of  blood,  and  minute  abscesses  were  seen  with  the  microscope  in  sections  of 
the  growth. 

Speaking  generally,  most  nsevi  can  be  recognised  by  the  presence  of  the 
remains  of  some  superficial  nevoid  tissue,  by  the  possibility  of  reducing  the 
size  of  the  growth  by  pressure — this  point  must  not,  of  course,  be  allowed  to 
mislead  in  swellings  about  the  head  or  spine — and  by  the  peculiar  spongy 


Fig. 


-Arterio-venous  varix. 


The  same  rule  applies 


428 


Diseases  of  the  Circulatory  System 


feeling.  This  sensation  is  sometimes  to  be  felt  in  a  growth  where  solid 
masses  are  also  perceptible.  The  fact  that  the  tumour  is  congenital  or  has 
been  noticed  in  very  early  life,  and  occasionally  the  presence  of  extravasa- 
tion of  blood  in  the  skin,  as  well  as,  of  course,  the  results  of  tapping,  will 
usually  clear  up  a  doubt. 

Certain   rare  forms  of  vascular  deformity  are  occasionally  met  with  in 
children.     In  a  case  of  our  own  the  condition  may  be  best  described  as 

arterio-venous  varix,  all  the  vessels  being- 
dilated  and  pulsatile  ;  the  facial,  orbital, 
and  intracranial  vessels  were  involved 
as  well  as  some  of  the  cerebral  sinuses, 
the  straight  sinus  being  converted  into 
a  pouch  as  large  as  a  thrush's  ^gg  and 
its  walls  calcified'  (fig.  84). 

Aneicrism  by  anastoinosis  is  also  oc- 
casionally met  with  in  children,  and 
sometimes  ligature  of  a  main  vessel, 
such  as  the  carotid,  may  be  required, 
as  also  in  some  cases  of  arterial  varix. 
St.  Germain  relates  three  cases  of  cirsoid 
aneurism  cured  by  the  use  of  chloride 
of  zinc  arrows.  ( Vide  '  Chirurgie  des 
Enfants,'  1884.)  Excision  is  usually  the 
best  treatment. 

NcBviis  lipoviatodes  is  the  term  ap- 
plied to  a  form  of  degenerated  njevus 
in  which  there  is  much  development  of 
fatty  tissue  forming  masses  which  often 
hang  in  pendulous  folds  ;  there  is  com- 
monly pigmentation  and  hairy  over- 
growth. The  condition  is  rare,  and 
appears  to  be  associated  with  idiocy, 
as  in  the  typical  case  under  our  care, 
from  which  fig.  85  was  taken.  No 
treatment  is  called  for  in  such  a  case.'- 
We  have  recently  (1895)  seen  a  female 
infant  a  few  weeks  old  with  an  almost 
exactly  similar  condition.  Occasionally, 
however,  where  merely  a  local  mass  is 
found,  it  should  be  removed  by  excision. 
This  was  the  treatment  adopted  for 
the  child  shown  in  fig.  86,  where  the  pendulous  hairy  mass,  closely 
resembling  the  so-called  'pachydermatocele,'  was  excised  with  a  good 
result. 

]byinphatic  Nsevi. — Lymphatic  neevi  are  much  rarer  than  blood  ntevi, 
but  many  of  the  so-called  congenital  cystic  growths  should  be  classed  as 

1  A  full  report  of  the  case  here  alluded   to  will   be  found   in   the   Abstracts  of  the 
Children's  Hospital  for  1882-83.      Vide  also  T.  Smith,  Clin.  Soc.  Trans.  1882. 

^  Hyde  of  Chicago  has  recorded  a  very  similar  case  in  the  Lancet,  August  i,  1885. 


Fig.  85. — Nsevus  Lipomatodes.  The  darkly 
pigmented  pendulous  masses  were  com- 
posed of  fat  and  degenerated  naevus  tissue, 
and  the  whole  surface  was  thickly  over- 
grown with  hair.  As  usual  in  these  cases, 
the  child  was  idiotic. 


NCBVUS 


429 


cystic  lymphangiomata.  Instances  of  this  condition  are  seen,  as  shown  by 
Virchovv,  in  niacroglossia,  described  at  p.  176. 

Hygroma  and  one  form  of  so-called  'giant  foot'  are  similar  conditions 
(tig.  87).  Sometimes  in  giant  foot  the  cutaneous  lymphatics  are  clearly  visible 
as  transparent,  dilated,  tortuous  canals  running  in  the  skin  :  the  part  is  greatly 
enlarged,  and  spongy  on  pressure.  The  disease  is  a  rare  one,  and  probably 
pressure  or  cautery  puncture  would  be  the  most  successful  mode  of  treatment. 
Treves  has  recorded  a  case  in  which  ulceration  has  occurred,  and  c|uotes 
Busey  that  congenital  giant  foot  is  commoner  in  females,  and  most  frequent 
in  the  right  leg  ;  the  temperature  of  the  part  may  or  may  not  be  raised. 
Ulcers,  if  they  occur,  readily  heal. 

Occasionally  in  niacroglossia,  as  in  a  case  of  ours,  the  superficial  lym- 
phatics form  minute  transparent  cysts  on   the  surface  of  the  tongue  ;  here 


Fig.  87. — Lymphatic  Nsevus  of  the 
Foot.  The  soles  of  the  two  feet  are 
seen,  and  in  the  affected  one  the 
extremities  of  the  toes  can  just  be 
made  out,  embedded  in  the  mass  of 
nsevus  tissue.  Dilated  and  varicose 
lymphatics  were  visible  in  the  skin. 


Fig.  86. — Degenerated  Naevus  of  Scalp. 

removal  of  part  of  the  tongue  might  possibly  be  required  to  prevent  suffocation, 
since  these  growths  are  liable  to  rapid  increase  in  size.  A  large  tumour  of  the 
thigh,  of  congenital  origin,  that  we  removed  a  short  time  ago  from  a  child  of 
2\  years,  was  made  of  spongy  tissue  exactly  like  a  nasvus,  but  the  spaces 
were  filled  with  lymph  instead  of  blood  ;  other  similar  cases  have  been 
recorded.  ( Vide  also  chapter  on  Tumours.)  Hoggan  has  described  multiple 
lymphatic  ntevi  of  the  skin,  a  condition  believed  commonly  to  accompany 
blood  n^evi,  and  to  be  much  more  frequent  than  is  supposed  ;  these  growths 
are  not  conspicuous  by  their  colour,  and  are  therefore  commonly  overlooked  ; 
they  are  of  little  clinical  importance,  unless  probably  as  an  early  stage  of 
elephantiasis.  We  have  also  met  with  instances  of  these  nsevi.^  Cases  of 
1  Hoggan,  Jour,  of  Aiiat.  and  Phys.  April  1884.     Lancet,  1882,  vol.  ii.  p.  891. 


430 


Diseases  of  the  Circulatory  System 


probably  congenital  lymphatic  varices  of  the  limbs  have  been  described  by 
R.  W.  Parker  ;  he  thinks  they  have  a  tendency  to  become  locally  inflamed.^ 
We  have  recently  met  with  a  case  of  lymph  ncevus  of  the  conjunctiva  and 
supra-orbital  region,  causing  an  unsightly  deformity  ;  the  nsevus  varied  much 
in  size,  and  sometimes  'puffed  up'  and  became  painful.- 

Large  multilocular  cystic  swellings  may  be  met  with  in  the  neck,  re- 
sembling in  external  appearance  the  hygromata  which  are  associated  with 
lymphatic  macroglossia,  but  differing  from  these  lymphatic  tumours  in  that 
some  of  the  cysts  are  found  filled  with  blood  either  coagulated  or  more  or 
less  altered,  and  become  '  laky.'  In  the  same  swelling  cysts  may  contain 
fluid,  clear  or  only  tinged  with  blood.  It  is  difficult  in  such  cases  to  be  sure 
whether  the  growth  is  a  blood  naevus  which  has  undergone  cystic  degenera- 
tion, or  a  lymph  nsevus  in  which  haemorrhages  have  taken  place.  Such  a 
case  which  we  saw  with  Dr.  McNicoll,  of  Southport,  occurred  in  a  child  of 


Fig. 


-Gangrene  of  the  leg  secondary  to  embolism  of  femoral  artery.     Boy,  aged  7  years, 
with  mitral  and  aortic  disease. 


seven  weeks  old  ;  and  as  it  was  growing  and  threatened  to  cause  dyspnoea,  it 
was  treated  by  laying  open  and  partly  removing  the  larger  cysts.  The  opera- 
tion, though  extensive  and  formidable  for  so  young  a  child,  had  a  satisfactory 
result. 

Excision  of  the  greater  part  of  the  cyst  wall  with  subsequent  drainage  is, 
we  have  found,  the  best  treatment.  If  the  drain  is  removed  too  soon  and 
insufficient  irritation  is  set  up,  the  lymph  cavity  is  apt  to  refill. 

Aneurism  in  children  is  extremely  rare  ;  only  a  few  cases  have  been 
recorded,  and  these  appear  all  to  have  been  either  traumatic  or  the  result 

1    Vide  also  chap,  on  Tumour  Growths  in  Childhood. 

-  The  case,  with  a  drawing,  has  been  published  by  Dr.  Mules  in  Trans.  Ophthalm. 
Cong. ,  Heidelberg,  1888.  For  an  account  of  various  rare  abnormalities  of  the  blood  and 
lymph  vascular  systems  (also  Nerven- Naevus,  &c.)  the  reader  is  referred  to  Esmarch  and 
Kulenkampff's  monograph  on  Elephantiasis. 


Aneurism — Embolism  431 

of  embolism,  the  embolus  giving  rise  to  softening  of  the  arterial  coat,  and  con- 
sequent formation  of  the  aneurism.  A  paper  on  this  subject  by  R.  W.  Parker  in 
the  '  British  Medical  Journal,'  1 884,  may  be  consulted.  We  have  only  met  with 
one  case  of  aneurism,  in  a  child  aged  seven  years,  who  was  suffering  from 
ulcerative  endocarditis  ;  the  aneurism,  which  was  situated  on  the  left  middle 
cerebral  artery,  was  no  doubt  due  to  an  embolus  ;  it  finally  ruptured  and  gave 
rise  to  extensive  meningeal  haemorrhage.  Dr.  A.  Jacobi  has  reported  several 
cases  of  aneurism  in  children,  due  to  atheromatous  degeneration,  one  case 
of  the  descending  aorta  in  a  girl  of  seven  years.  Sanne  has  reported  four 
cases,  one  in  a  foetus,  and  three  in  children  of  two,  ten,  and  thirteen  years 
respectively. 

Embolism  occurs  not  infrequently  during  early  life  in  children  suffering 
from  acute  or  malignant  endocarditis  ;  it  may  occur  in  any  form  of  valvular 
heart  disease.  Embolism  of  a  cerebral  artery  may  give  rise  to  hemiplegia 
and  softening  (see  p.  409).  Embolism  of  the  spleen  is  found  not  unfrequently 
post  mortem.  In  a  patient  of  our  colleague  Dr.  Hutton,  who  was  suffering 
from  mitral  and  aortic  disease,  embolism  of  the  femoral  artery  occurred 
followed  by  gangrene  of  the  leg.  The  leg  was  amputated  by  Mr.  Collier 
and  the  boy  made  a  good  recovery  as  far  as  the  stump  was  concerned. 


432        Diseases  of  the  Blood  and  Blood-making   Organs 


CHAPTER  XX 

DISEASES    OF   THE    BLOOD   AND    BLOOD-MAKING   ORGANS 

Anaemia 

Children  of  all  ages  are  liable  to  suffer  from  anaemia,  from  causes  both 
known  and-unknown.  Some  children  are  habitually  pallid,  without,  perhaps, 
being  in  any  way  out  of  health  ;  and  this  peculiarity  seems  to  run  in  families. 
In  the  majority  of  cases  ansemia  means  ill  health,  the  poorness  of  blood  being 
due  to  one  or  other  of  a  great  variety  of  ailments.  It  is  unnecessary  for 
us  to  describe  the  anemia  which  is  due  to  obvious  causes,  such  as  tuberculosis, 
heart  disease,  syphilis,  malaria,  or  the  anaemia  which  is  the  result  of  some 
acute  disease.  We  will  chiefly  confine  our  remarks  to  certain  forms  in  which 
the  anaemia  is  often  profound  and  the  pathology  by  no  means  certain.  A 
slight  acquaintance  with  the  forms  of  anaemia  from  which  children  suffer  will 
be  sufficient  to  convince  anyone  that  there  are  different  forms  of  diverse  groups. 
Thus  we  have  anaemia  accompanied  by  great  enlargement  of  the  spleen,  and 
an  anaemia  in  which  no  such  enlargement  is  present.  We  have  the  so-called 
Pernicious  Anaemia,  which  appears  always  to  go  on  to  a  fatal  issue.  In  some 
cases  there  is  a  tendency  to  purpura,  and  while  in  all  forms  of  anaemia 
haemorrhages  are  common  when  the  anaemia  becomes  extreme,  yet  in  some 
cases  purpura  is  an  early  symptom,  and  makes  its  appearance  without  the 
anaemia  being  very  great.  The  groups  into  which  we  divide  these  cases  are 
selected  rather  for  convenience  of  description  than  from  their  actually  form- 
ing independent  or  '  self-standing  forms '  of  disease. 

It  is  unnecessary  to  say  that  an  examination  of  the  blood  gives  important 
mformation  with  regard  to  the  nature  of  the  anaemia,  and  is  therefore  of  use 
as  regards  prognosis  and  treatment.  For  the  details  of  the  methods  of  this 
examination  we  must  refer  the  reader  to  the  various  clinical  manuals.^ 

The  examination  includes  (i)  The  estimation  of  the  amount  of  haemo- 
globin present  as  measured  by  Fleischl's  haemometer.  In  healthy  children 
there  may  be  85  to  95  per  cent.,  in  profound  anaemia  as  little  as  30  to  35  per 
cent. 

(2)  Counting  the  number  of  the  red  and  white  corpuscles,  by  means  of 
the  Thoma-Zeiss  apparatus.  In  round  numbers  in  healthy  children  there  are 
five  million  red  corpuscles  to  the  cubic  millimetre  ;  m  some  forms  of  anaemia 
the  number  may  sink  to  two  millions.  The  number  of  white  corpuscles  varies 
from-  8,000  to  9,000  (Limbeck)  in  children,  and  from  12,000  to  13,000 
(Gunrobin)  per  cubic  millimetre  in  infants  under  a  year. 

(3)  A  microscopical  examination  "of  the  red  corpuscles  to  determine  their 
shape,  size,  and  colour.     In  extreme  forms  of  anaemia  there  may  be  some 

1  Or  see  Kanthack  '  On  Blood  Changes  in  Diseased  Conditions,'  Medical  Chronicle, 
July,  August,  October  1894. 


Ancemia  -  433 

nucleated  red  corpuscles  present,  and  the  corpuscles  may  be  misshapen  and 
very  pale. 

(4)  A  film  of  dried  blood  is  stained  with  eosin  and  methyl  blue  in  oi"der 
to  distinguish  between  the  varieties  of  white  corpuscles  present,  and  to  de- 
termine their  relative  proportion.  Following  Ehrlich's  methods,  Kanthack 
distinguishes  the  following"  varieties  : 

{li)  liympliocytes,  consisting  of  small  cells  with  a  large  blue  nucleus  and 
narrow  zone  of  clear  protoplasm  ;  they  are  supposed  to  derive  their  origin 
from  lymphatic  gland  tissue.  [U)  Karg-e  uninuclear  cells,  consisting  of 
cells  with  a  large  oval  or  indented  nucleus,  and  a  large  zone  of  surrounding 
clear  protoplasm.  They  are  supposed  to  be  derived  from  the  marrow  of 
bone  and  spleen,  {c)  Finely  granular  or  polynuclear  (neutrophile)  cells. 
The  nucleus  is  multipartite,  and  lobed.  The  protoplasm  is  filled  with  granules 
which  stain  with  eosin.  The  number  of  these  cells  is  increased  in  febrile 
conditions  :  they  are  in  normal  conditions  in  adults  the  most  numerous  of 
the  white  corpuscles  present.  id)  Coarsely  grranular  eosinophlle  cells  : 
they  have  a  single  round  or  horseshoe  nucleus,  the  protoplasm  has  coarse 
granules  which  stain  strongly  with  eosin. 

As  regards  the  relative  numbers  of  these  in  the  blood  of  healthy  adults 
and  infants,  the  following   numbers  may  be  taken  as  approximately  true. 
Lymphocytes,  adults  20  per  cent,  infants  under  one  year  59  per  cent. 
Large  uninuclear  cells,  adults  6  per  cent.,  infants  6  per  cent. 
Finely  granular  neutrophile  cells,  adults  75  percent,  infants  31  per  cent. 
Coarsely  gi-anular  eosinophile  cells,  adults  2  per  cent,  infants  3  per  cent. 
(Uskoffj,  (Gunrobin). 

From  this  it  would  appear  that  in  early  life  the  lymphocytes  are  increased 
at  the  expense  of  the  finely  granular  or  neutrophile  cells. 

Anaemia  with  (Edema. — In  all  cases  in  which  the  anaemia  is  great  there 
is  a  tendency  to  the  accumulation  of  serum  in  the  serous  cavities,  and  a 
liability  to  subcutaneous  oedema.  In  the  out-patient  department  of  hospital 
practice  it  is  common  to  meet  with  infants  or  children  under  two  years  of  age 
who  are  aneemic,  and  at  the  same  time  oedematous,  the  back  of  their  hands 
and  feet  readily  pitting.  Such  cases  are  often  looked  upon  as  suffering 
from  nephritis,  but  the  urine  is  mostly  free  from  albumen  and  casts.  There 
is  usually  no  enlargement  of  the  spleen.  These  cases  are  commonly  seen  in 
the  autumn  in  children  who  have  suffered  from  acute  diarrhoea  or  some  other 
exhausting  disease  which  has  given  rise  to  great  aneemia.  The  anaemia  is 
due  to  the  great  drain  on  the  system  during  acute  or  long-continued  disease, 
or  possibly  it  may  be  the  result  of  the  action  of  toxic  albumens  or  peptones 
absorbed  into  the  blood  from  the  alimentary  canal.  We  must  also  remem- 
ber that  the  arterial  pressure  in  young  children  is  normally  very  small,  and 
easily  reduced  by  acute  disease.     (See  NEPHRITIS.) 

Simple  Anaemia — Chlorosis. — There  is  a  class  of  case  mostly  occurring 
in  older  children  which  resembles  the  chlorosis  of  adults.  There  is*  no 
enlargement  of  the  spleen,  no  purpura  or  any  evidence  of  organic  disease. 
The  children  are  markedly  bloodless,  languid  and  easily  get  out  of  breath  ; 
murmurs  may  be  heard  at  the  base  of  the  heart,  and  in  the  veins  and  arteries 
of  the  neck.  Both  girls  and  boys  may  be  affected  in  this  way  about  puberty. 
In  one  instance  coming  under  our  notice,  two  brothers  and  a  sister,  aged  8^^, 

F  F 


434        Diseases  of  the  Blood  and  Blood-making  Organs 

7,  and  5f  years,  suffered  in  this  way  ;  their  mother  was  also  anaemic.  They 
were  intensely  anemic,  and  were  drowsy  and  lethargic.  They  were  fairly  well 
nourished  as  far  as  fat  was  concerned  ;  there  was  no  splenic  enlargement, 
no  albumen  in  the  urine,  and  no  hsemorrhages.  In  all  three  there  was  an 
irregular  pyrexia,  a  rise  of  a  degree  or  two  taking  place  most  evenings.  An 
examination  of  the  blood  showed  a  diminution  of  red  blood  corpuscles,  and 
no  striking  excess  of  white  corpuscles.  They  all  three  improved  consider- 
ably during  their  stay  in  hospital.  It  is  well  to  bear  in  mind  that  such  cases 
are  exceedingly  apt  to  suffer  from  tubercle. 

Idiopathic  or  Pernicious  Anaemia  is  apt  to  occur  in  children  ;  out  of 
I02  cases  published  by  Dr.  Pye  Smith  in  the  Guy's  Hospital  '  Reports'  for 
1882  there  were  six  between  the  ages  of  seven  and  fifteen  years.  It  has  been 
met  with  in  children  of  all  ages.  Kjellberg  has  recorded  a  case  in  a  boy  of 
five  years,  Elben  in  a  girl  of  three  years,  and  W.  Steffen  in  a  girl  of  sixteen 
months.     It  is  always  fatal. 

No  cause  can  usually  be  assigned  for  the  ansemia  ;  in  one  case  coming 
under  our  notice  the  child  had  been  much  neglected  and  badly  fed. 
Schapiro  reports  a  case  of  a  girl  of  13  years  who  was  supposed  to  suffer 
from  pernicious  anaemia,  but  began  to  improve  after  passing  a  tape-worm — • 
Bothriocephalus  latus. 

The  symptoms  and  course  are  exactly  the  same  in  children  as  in  adults. 
The  first  symptoms  are  those  ofweakness,breathlessness,  and  pallor,  coming 
on  without  cause.  The  anaemia  becomes  extreme,  the  skin  is  blanched  and 
of  an  earthy  tinge  ;  the  conjunctivae  and  mucous  membrane  of  the  mouth 
are  pallid,  and  the  muscles  weak  and  flabby.  Usually  there  is  no  great  loss 
of  flesh.  Vomiting  is  not  uncommonly  a  marked  symptom.  In  some  cases 
there  appears  to  be  a  slight  rise  of  temperature  at  night,  101°  or  102°  ;  in  this 
respect  pernicious  anaemia  resembles  other  forms  of  anaemia.  Purpuric  spots 
are  sometimes  present  on  the  skin,  and  retinal  haemorrhages  and  optic 
neuritis  may  take  place  (S.  Mackenzie). 

An  examination  of  the  blood  in  an  advanced  case  shows  a  very  marked 
diminution  of  the  red  blood  corpuscles  without  any  leucocytosis,  indeed  the 
white  corpuscles  are  usually  diminished,  and  a  considerable  number  of  large 
red  corpuscles  (megaloblasts)  are  present.  In  a  case  of  pernicious  anaemia 
which,  as  we  have  already  remarked,  is  an  exceedingly  fatal  disease,  dia- 
gnosis is  of  great  importance.  It  is  most  likely  to  be  mistaken  for  some  form 
of  secondary  anaemia,  in  which  there  has  been  severe  haemorrhage,  or  the 
feeding  has  been  bad  as  in  scurvy.  The  following  are  the  chief  points  to  be 
noted  in  examining  the  blood.     See  Kanthack  (loc.  cit.). 

Chlorosis  Secondary  A ncemia  Pernicious  Ancsmia 

Red  blood  corpuscles  slightly  Red  blood  corpuscles  re-  Red  blood  corpuscles  greatly 
reduced   in   number ;    Hb         duced ;    marked    decrease  reduced,    Hb   diminished, 

considerably  reduced.  of  Hb.  but  not  in  proportion. 

Red  corpuscles  retain  their  Nucleated  red  corpuscles  Nucleated  red  corpuscles 
size  and  shape,  nucleated  present ;  red  corpuscles  extremely  common  ;  they 
red  corpuscles  rare.  vary  in  size  and  shape.  are  easily  injured. 

No  leucocytosis.  In  acute  cases  there  is  leuco-     No   leucocytosis,    usually   a 

No  large  red  corpuscles  cytosis  due  to  an  increase  diminution. 

present.  in     the     number    of    the      Large    red    corpuscles    are 

polynuclear  leucocytes.  present. 

No  large  red  corpuscles. 


A  nceni  ia — Sai  rvy  '  435 

The  course  is  often  acute,  usually  varying  from  one  month  to  three 
months. 

Morbid  Anatfliny. — All  the  organs  are  in  a  bloodless  condition,  the 
muscles  are  in  a  state  of  fatty  degeneration,  and  minute  haemorrhages  are 
found  on  the  surfaces  of  the  organs.  There  is  no  further  alteration  found 
in  the  spleen  or  other  viscera. 

The  following  case  illustrates  many  of  the  above  points  : 

Pernicious  AncBmia. — Walter  H.,  aged  ir^  years,  has  been  getting  pale  and  weak  for 
six  months,  no  cause  known  ;  has  had  hollow  cough  and  frontal  headache ;  for  two 
months  has  had  frequent  epistaxis,  and  for  some  time  has  had  fainting  fits,  and  spots 
'  like  bruises '  have  appeared  on  thighs  and  shins  ;  no  bleeding  from  lungs  or  bowels 
noticed.  Mother  strong,  father  said  to  have  been  phthisical  in  early  life  ;  brothers  and 
sisters  all  rickety  and  ansemic,  four  of  them  now  in  hospital  with  scarlet  fever  ;  all  re- 
covering. Admitted  August  30.  Large,  well-formed,  well-nourished,  and  muscular  boy, 
dark  brown  hair  and  eyes,  height  4ft.  /in.,  intelligent,  intensely  anaemic,  tongue  furred, 
pale  and  fissured,  fauces  pale,  tonsils  large  ;  respiration  34,  fairly  deep  ;  pulse  146,  regu- 
lar and  full  ;  temperature  103°  ;  both  bases  dull,  with  weak  respiratory  sounds,  no  crepi- 
tation, heart's  area  normal,  impulse  heaving  and  visible  over  second  to  fifth  spaces,  sounds 
at  left  base  murmurous,  spleen  and  liver  not  felt  in  abdomen,  blood  watery  and  pale  ;  red 
corpuscles,  generally  normal  in  shape  and  form  characteristic  rouleaux,  a  few  are  elon- 
gated ;  white  corpuscles  only  slightly  increased  relatively,  vary  much  in  size,  most  of  them 
being  smaller  than  usual ;  urine  1016,  pale,  no  albumen,  no  excess  of  urates  or  phosphates  ; 
ordered  citrate  of  iron.  August  31. — Temperature  now  between  normal  and  100°. 
September  6. — Temperature  still  below  100°  ;  respiration  32  ;  pulse  148  ;  no  cough,  no 
night  sweating,  has  attacks  of  syncope  on  attempting  to  sit  up,  has  vomited  twice  to-day, 
no  cardiac  murmur.     Died  September  7. 

Post-mortem. — Forty  hours  after  death  body  well  nourished,  intensely  ansemic,  rigor 
mortis  persists,  a  few  ounces  of  serum  in  each  pleural  cavity,  patches  of  emphysema 
along  margins  of  lungs,  no  consolidation,  abundant  sub-pleural  ecchymoses  ;  about  2  oz. 
clear  serum  in  pericardium,  no  pericarditis,  no  endocarditis,  abundant  sub-pericardial 
ecchymoses,  tricuspid  orifice  admits  three  fingers,  muscular  fibre  pale  ;  much  '  tabby-cat ' 
mottling  of  endocardium.  Spleen  3^  oz. ,  soft  and  friable  ;  liver  34^  oz. ,  very  anaemic  ; 
kidneys  45  oz. ,  very  soft,  intensely  anasmic,  capsules  peel  off  readily. 

Baginsky  ^  records  a  case  of  pernicious  anaemia  in  a  child  of  3^^  years.  It 
suffered  from  haemophilia  for  a  year  before  its  death.  When  seen  it  was  very 
pale,  the  liver  and  spleen  were  enlarged.  An  examination  of  the  blood 
showed  only.  2,680,000  red  blood  corpuscles  per  cubic  millimetre,  and  only 
17  per  cent.  Hb  (Fleischl).  The  proportion  of  white  corpuscles  to  red  was 
I  in  100.  The  red  blood  corpuscles  had  undergone  change  of  shape  ;  there 
were  megalo-blasts  and  nucleated  red  corpuscles,  many  large  uninuclear  cells, 
and  a  small  number  of  the  multinuclear.     No  eosinophile  cells. 

Treatment. — The  medicines  most  likely  to  be  of  service  are  iron  and 
arsenic.  Phosphorus  and  cod  liver  oil  have  been  used  with  some  success 
Bone  marrow  and  raw  meat  juice  should  be  given.  In  the  majority  of  cases 
the  progress  is  from  bad  to  worse. 

Scurvy. — A  scorbutic  state  may  sometimes  be  met  with  in  children  as 
the  result- of  bad  or  improper  food,  especially  if  fresh  vegetables  have  been 
excluded  from  it  ;  such  are  cases  of  true  scurvy,  similar  in  every  respect  to 
those  which  used  to  occur  so  frequently  among  seamen.  A  similar  condition 
is  met  with  in  association  with  certain  depressing  diseases  such  as  tuberculosis. 
At  other  times  when  it  occurs  it  is  difficult  to  assign  any  cause. 
1  Berliner  Klin.   Woch.  20,  1894. 


436        Diseases  of  the  Blood  and  Blood-making  Organs 

The  patient  is  usually  anaemic,  though  he  may  be  well  nourished  as  far 
as  subcutaneous  fat  is  concerned  ;  the  gums  are  spongy  and  offensive,  they 
bleed  with  the  slightest  injury,  the  teeth  are  loose  and  may  fall  out  ;  haemor- 
rhage is  apt  to  occur  from  the  nose,  kidneys,  and  bowels  ;  purpuric  spots  are 
common,  and  bruising  occurs  after  the  slightest  injuries.  The  majority  of 
the  cases  which  come  under  our  notice  in  hospital  quickly  improve  with 
proper  dieting  and  careful  nursing.  In  one  of  our  cases,  where  a  scorbutic 
condition  was  present  in  a  boy  often  years  in  association  with  fibroid  phthisis, 
improvement  took  place  on  several  occasions  when  we  had  him  in  hospital, 
but  he  eventually  died  from  exhaustion,  the  result  of  frequent  haemorrhages. 
At  the  post-mortem  a  chronic  tuberculosis  was  found,  but  nothing  was 
found  to  explain  the  htemorrhagic  condition  suffered  from  during  life.  (See 
Infantile  Scurvy,  p.  192.) 

Treatine7it. — In  all  cases  where  there  is  anemia,  with  spongy  gums  and  a 
tendency  to  hsemorrhage,  lemon  or  orange  juice  should  be  given,  and  fresh 
vegetables  in  some  form  or  other  should  enter  into  the  diet.  Scraped 
underdone  meat,  beef  juice  and  eggs  are  also  necessary.  The  gums  should  be 
carefully  cleaned,  and  painted  with  glycerine  of  tannin,  borax  and  tincture 
of  myrrh,  or  some  other  antiseptic.  Iron  and  cod  liver  oil  should  be  given 
internally.  Hfemostatics,  such  as  ex.  hamamelis  liq.,  gallic  acid,  and  turpen- 
tine, will  often  be  required. 

Enlarg-ed  Spleen 

The  spleen  is  a  very  vascular  organ,  is  functionally  more  active  in  child- 
hood than  in  after  life,  and  is  more  apt  to  become  temporarily  engorged 
and  enlarged.  The  best  method  of  determining  the  enlargement  during 
early  life  is  by  palpation  rather  than  by  percussion,  as  the  lesser  rigidity  of 
the  abdominal  walls  during  early  childhood  usually  readily  permits  of  this. 
Palpation  of  the  spleen  is  effected  by  standing  at  the  patient's  right  side 
and  gently  pressing  two  or  three  fingers  of  the  right  hand  into  the  left  hypo- 
chondrium  beneath  the  costal  arch,  when  the  lower  and  inner  edge  of  the 
spleen,  if  it  is  enlarged,  can  be  readily  felt  as  a  movable  tumour  which  can  be 
pressed  upwards.  It  can  hardly  be  said  that  the  spleen  is  abnormally  en- 
lai'ged  unless  its  lower  edge  extends  below  the  costal  arch.  Enlargement  is 
very  common  during  childhood,  and  accompanies  various  conditions.  An  en- 
larged spleen  is  most  frequently  associated  with  an  ansemic  condition,  though 
exactly  what  the  relation  between  the  two  is  is  uncertain  (see  p.  437).  An 
enlarged  spleen  is  also  met  with  when  the  portal  system  is  obstructed,  as  in 
cirrhosis  of  the  liver.  In  two  cases  coming  under  our  notice  the  spleens 
were  greatly  enlarged,  and  in  these  cases  it  is  quite  possible  to  overlook  the 
cirrhosis  of  the  liver  and  look  upon  the  case  as  one  in  which  the  splenic 
enlargement  is  due  to  Hodgkin's  disease  or  some  anaemic  condition.  It  is 
enlarged  in  many  cases  of  rickets  and  syphilis,  though  certainly  not  in  all 
cases  ;  it  is  chiefly  so  in  those  cases  in  which  pallor  and  anaemia  are  marked 
symptoms.  It  is  enlarged  and  hard  in  ague,  and  also  when  lardaceous  and 
in  association  with  leucocythcemia  and  Hodgkin's  disease.  It  is  also  en- 
larged in  various  acute  diseases,  such  as  typhoid  fever,  acute  tuberculosis 
and  pyjEmia,  and  in  some  other  febrile  states,  such  as  ulcerative  endo- 
carditis. 


Aiueinia  Splenica  437 

Aneemia  Splenica.     Anaemia  Infantum    Pseudoleukaemia. —  In    an 

ill-dertned  group  of  cases,  occurring  mostly  in  children  under  two  years 
of  age,  the  annemia  is  often  profound,  and  the  spleen  strikingly  enlarged. 
Sometimes  mothers  will  bring  such  children  for  treatment,  as  they  have 
already  noticed  the  large  spleen  as  well  as  the  paleness  of  the  child.  There 
is  usually  a  history  to-be  obtained  of  ill  health,  more  especially  of  aggravated 
indigestion,  or  some  acute  illness,  and  nearly  all  of  them  exhibit  evidence 
of  rickety  deformities.  In  a  well-marked  case,  the  anaemia  strikes  the 
observer  at  once  as  being  much  out  of  the  common ;  the  lips  are  a 
pale  pink,  and  the  face  is  white  or  of  a  slightly  yellow  tint ;  on  placing 
the  hand  on  the  abdomen,  the  edge  of  the  spleen  is  distinctly  felt  (it  can 
sometimes  be  seen),  and  the  tip  can  be  traced  downwards  on  a  level  with, 
or  below,  the  umbilicus.  There  may  be  enlargement  of  the  liver.  The 
unne  is  free  from  albumen,  and  except  quite  at  the  termination  of  the  case, 
there  are  no  hccmorrhages  and  no  oedema.  There  is  often  irregular  and 
intermittent  pyrexia.  The  course  is  essentially  chronic  ;  the  patients  usually 
improve  slowly  under  treatment  in  hospital  with  careful  diet  and  tonic 
medicines.  They  readily  succumb  to  intercurrent  diseases,  such  as  measles 
or  pneumonia.  In  the  worst  class  of  case  the  anaemia  becomes  more  and 
more  profound,  and  they  die  exhausted  ;  in  the  later  stages  there  may  be 
haemorrhages,  purpura,  and  oedema.  On  the  other  hand,  we  meet  with 
'  borderland  '  cases,  where  there  is  a  moderate  degree  of  anaemia  and  splenic 
enlargements,  with  perhaps  well-marked  signs  of  rickets.  The  pathology 
of  these  cases  is  very  obscure  ;  an  examination  of  the  spleen  post  inortetn 
shows  it  to  be  hypertrophied,  firm,  and  hard,  and  on  section  it  is  of  a  dark 
purple  colour  ;  a  microscopical  examination  shows  nothing  beyond  hyper- 
trophy. The  etiology  of  these  cases  is  no  less  uncertain.  The  condition 
closely  resembles  that  seen  in  malaria,  but  in  this  country  this  can  be  ex- 
cluded with  certainty.  In  a  certain  proportion  of  the  cases  a  history  of 
syphilis  can  be  obtained  ;  in  thirty  cases  reported  by  Carr  ^  there  was  a 
history  of  syphilis  in  eight,  a  doubtful  history  in  six,  and  in  sixteen  no  history 
could  be  obtained.  In  sixty-three  cases  reported  by  Fox  and  Ball  -  in  forty- 
one  per  cent,  there  was  a  history  of  syphilis  to  be  obtained.  The  figures  of 
the  last  observers  surprise  us  ;  our  experience  has  been  that  a  definite  history 
of  syphilis  is  uncommon,  and  certainly  in  a  large  majority  of  our  cases  no 
history  of  syphilis  could  be  obtained.  It  is  true  that  syphilis  produces  both 
anaemia  and  enlargement  of  the  spleen,  especially  during  the  acute  phases  ; 
but  we  are  not  aware  of  any  cases  of  syphilis  having  been  under  observation 
during  the  acute  stage  and  having  then  passed  into  (while  under  observation) 
a  condition  of  splenic  ansemia.  That  there  is  a  close  connection  between 
this  condition  and  rickets  is  certain,  as  almost  all  such  children  exhibit 
evidence  of  rickety  changes  in  the  bones,  and  this  ansmic  state  occurs 
almost  exclusively  during  the  first  two  years  of  life,  when  rickets  is  most 
common.  We  are  inclined  to  agree  with  Carr  in  believing  that,  while  both 
syphilis  and  rickets  may  play  a  role  in  producing  this  condition  of  splenic 
anaemia,  they  are  neither  of  them  the  sole  or  efficient  cause,  but  that  con- 
genital weakness,  chronic  dyspepsia,  bad  feeding,  and  insanitary  conditions 

1  Lancet,  April  23,  1892.  ^  Brit.  Med.  Jour.  April  1892. 


438        Diseases  of  the  Blood  and  Blood-making  Organs 

may  interfere  with  the  blood-makhig  organs  and  lead  to  a  condition  of  pro- 
found ansemia. 

Hock  and  Schlesinger  ^  draw  a  distinction  between  Anceiiiia  infa7itinn 
pseiidoleukceniia  and  Ananiia  splenica.  The  first  rather  awkward-sounding 
name  was  appHed  by  Jaksch  to  cases  in  which  there  was  anaemia,  en- 
larged spleen,  and  leucocytosis  ;  the  latter  to  a  class  of  case  in  which  there 
was  ansemia,  enlarged  spleen,  but  no  leucocytosis.  How  far  this  distinction 
can  be  maintained  we  are  not  prepared  to  say,  but  there  is  a  strong  pro- 
bability, we  think,  that  there  may  be  different  causes  at  work  in  producing 
ansemia  with  splenic  enlargement  in  young  children,  and  we  are  hardly 
in  a  position  to  accord  to  this  class  a  position  among  the  '  self-standing ' 
diseases. 

In  three  cases  in  which  the  blood  was  examined  by  Felsenthal'-  in  children 
(ages  ten  months  to  one  and  a  quarter  years)  suffering  from  well-marked 
anaemia,  enlarged  spleen,  a  comparatively  small  liver,  no  lymphatic  en- 
largement and  well-marked  signs  of  rickets,  he  found  that  the  amount  of 
haemoglobin  was  as  low  as  thirty  to  forty  per  cent.,  the  number  of  red  cor- 
puscles about  three  million  per  cubic  millimetre,  the  leucocytes  forty  to  forty- 
five  thousand,  there  were  many  nucleated  red  blood  corpuscles,  and  some  very 
large  red  ones  (megaloblasts).  The  number  of  lymphocytes  varied  from  40 
to  60  per  cent.  In  one  of  our  cases,  a  girl  of  fourteen  months,  our  resident 
medical  officer,  Dr.  H.  Wansborough  Jones,  on  examination  of  the  blood 
found  2,800,000  red  corpuscles  and  112,000  white  corpuscles  per  cu.  mill. 
The  haemoglobin  amounted  to  thirty  per  cent.  There  were  some  nucleated 
red  corpuscles,  and  some  megaloblasts  and  microcytes.  No  eosinophile  cells 
were  seen. 

While  in  a  vast  majority  of  cases  the  children  who  suffer  in  this  way  are 
under  two  years  of  age,  yet  occasionally  we  meet  with  older  children  who 
are  affected  in  a  similar  manner,  as  in  the  following  fatal  case  : 

Ancemia,  Enlarged  Spleen. — Thos.  Arthur  C,  aged  5  years.  Up  to  four  months  ago 
quite  healthy  ;  no  serious  ilhiess.  Has  Hved  always  in  Manchester.  Father  and  mother 
healthy.  Four  months  ago  had  a  fall,  not  confined  to  bed,  abdomen  painful  and  swollen 
ever  since,  two  months  ago  had  severe  epistaxis,  with  no  known  cause  ;  very  much  blanched 
ever  since,  feet  sometimes  swollen  ;  has  had  occasional  pain  and  twitchings  in  left  arm  for 
an  hour  at  a  time,  and  slight  twitchings  of  the  body  also.  On  admission,  December  29, 
1881,  plump,  with  marked  pallor,  a  few  purpuric  spots  on  thighs  and  feet;  superficial 
glands  generally  enlarged,  face  oedematous,  no  cedema  of  feet ;  abdomen  prominent  in 
epigastric  and  hypogastric  regions,  liver  and  spleen  much  enlarged,  heart  and  lungs  nil. 
Urine  1020  ;  no  albumen.  Temperature  103°  P.M.  June  2. — Loud  systolic  murmur  over 
whole  cardiac  area,  no  mediastinal  dulness  ;  heart's  area  increased,  apex  beat  felt  outside 
nipple  line.  Blood  thin  and  watery,  with  some  increase  of  white  corpuscles  ;  spleen 
rather  tender.  Temperature  irregular,  98°  to  101°  and  102°.  June  13.' — Constantly 
moaning;  temperature  still  high  and  irregular.  June  14. — Died  5  a.m.,  unconscious 
all  night.  Post-mortem. — Twelve  hours  after  death;  great  pallor,  some  oedema  of  ex- 
tremities ;  blood  very  fluid,  liver  unformly  enlarged,  pale  with  fine  yellow  points 
(hepatic  vessels).  No  perihepatitis,  spleen  5  in.  by  3  in.  ;  smooth,  firm,  purple  on  section. 
Retroperitoneal  glands  very  slightly  enlarged  ;  kidneys  firm  and  very  pale.  No  peritonitis, 
no  ascites,  no  staining  of  organs   with   iodine.     Heart. — Left   ventricle  hypertrophied  ; 

■    1  Hamatologische  Studien,  Leipsic,  1892. 
-  Archiv  fiir  Kinderheilkimde,  Heft  i.  u.  ii.  1892. 


Hodgkins  Disease  -  439 

right  ventricle  dilated,  subpericardialecchymoses,  valves  normal.  Lungs  emphysematous, 
with  abundant  ecchynioses  on  surface  and  in  substance.  No  enlarged  mediastinal  glands  ; 
brain  firm,  intensely  anaemic,  ctiierwise  a])parently  healthy.  No  venous  congestion,  no 
fluid  in  ventricles. 

Treatment. — Iron,  arsenic,  and  cod  liver  oil,  especially  the  former,  are  the 
drugs  most  likely  to  be  of  service  in  anaemia,  though  the  treatment  must 
necessarily  be  modified  according  to  the  cause.  The  cachexia  produced  by 
syphilis  must  be  treated  by  a  combination  of  iron  and  mercury,  with  cjuinine 
if  malaria  is  suspected.  Care  must  be  taken  to  see  that  the  bowels  are  acting 
normally. 

Raw  marrow  of  bone,  raw  meat  juice,  orange  juice,  peptonised  milk 
should  be  given. 

Hodg-kin's  Disease — Anaemia  Iiymphatica. — This  disease  is  charac- 
terised by  an  enlargement  of  various  groups  of  lymphatic  glands  and  also  of 
the  spleen  ;  there  is  progressive  antemia,  and  more  or  less  intermittent  fever. 
According  to  Gower's  statistics,  16  out  of  every  100  cases  occur  in  children 
under  10  years  of  age.  The  earliest  symptom  which  calls  attention  to  the 
disease  is  enlargement  of  some  lymphatic  glands,  usually  the  cervical,  though 
the  axillary  or  mediastinal  may  be  early  affected. 

The  glands  just  behind,  or  in  front  of  and  beneath,  the  sterno-mastoid  are 
frequently  the  first  to  be  enlarged,  or  the  group  at  the  angle  of  the  jaw  ;  the 
glands  at  first  are  firm  and  movable,  varying  in  size  from  time  to  time  as  if 
the  vessels  were  gorged  at  one  time  and  more  empty  at  another.  With  the 
glandular  enlargement  there  is  usually  a  marked  increase  in  size  of  the 
spleen,  and  the  child  becomes  weak  and  pallid.  A  prominent  feature  of  the 
disease  is  the  occurrence  of  attacks  of  pyrexia  ;  the  temperature  at  times 
continues  elevated  for  some  days,  or  it  may  assume  the  intermittent  type. 
Other  groups  of  glands  may  become  affected  ;  there  may  be  an  extension 
into  the  mediastinum,  and  the  glands  may  exert  pressure  on  the  trachea  or 
large  veins,  so  that  there  is  orthopncea,  oedema,  or  ascites.  The  axillary 
and  inguinal  glands  may  also  become  affected.  In  some  cases  the  external 
lymphatic  glands  may  be  but  little  affected,  but  the  mediastinal  or  retro- 
peritoneal glands  and  the  spleen  may  be  much  enlarged.  The  course  of 
the  disease,  is  very  chronic,  but  the  prognosis  is  unfavourable,  and  sooner  or 
later  the  child  dies  exhausted.  At  the  autopsy  the  spleen  is  found  enlarged 
and  infiltrated  with  an  adenoid  growth,  while  other  organs,  as  the  lungs, 
liver,  and  kidneys,  are  also  infiltrated,  only  in  less  degree. 

Diagnosis. — The  diagnosis  of  Hodgkin's  disease  in  an  early  stage  is  often 
extremely  difficult  where  the  patient  is  brought  with  a  mass  of  enlarged 
glands  in  the  neck  or  other  part.  If  the  glandular  tumours  vary  in  size  from 
time  to  time,  if  there  is  intermittent  pyrexia  or  enlarged  spleen,  Hodgkin's 
disease  may  be  suspected.  If  the  glands  suppurate  they  are  probably 
tubercular.  We  have  frequently  seen  enlarged  tubercular  cervical  and 
axillary  glands  mistaken  for  the  enlarged  glands  of  Hodgkin's  disease. 
Possibly  tubercular  disease  and  Hodgkin's  disease  may  co-exist. 

Treatjiient. — Arsenic  and  phosphorus  are  the  medicines  most  likely  to  be 
useful,  but  the  disease  generally  progresses  to  a  fatal  termination. 

Xieuksemia. — Leukai^mia  is  a  rare  disease  during  childhood,  but  the 
possibiHty  of  its  being  present  should  be  borne  in  mind  when  a  pallid  child 


440        Diseases  of  the  Blood  and  Blood-making  Organs 

with  a  large  spleen  presents  itself,  especially  if  on  examination  of  the  blood 
there  is  marked  leucocytosis.  It  occurs  at  all  ages  :  babies  at  the  breast 
have  been  affected,  and  also  those  more  advanced  in  years  ;  it  cannot  be 
said  that  anything  certain  is  known  about  its  etiology,  though  poor  living, 
various  depressing  conditions,  and  malaria  have  been  credited  with  producing 
it.  The  earhest  sj'mptom  to  call  attention  to  the  disease  is  abdominal 
distension,  which  is  found  to  be  due  to  a  greatly  enlarged  spleen  ;  with  this 
there  is  dyspepsia,  perhaps  abdominal  tenderness,  and  marked  ansemia. 
The  disease  is  a  chronic  one,  and  the  prognosis  unfavourable.  Like 
Hodgkin's  disease,  there  may  be  enlargement  of  lymphatic  glands  and 
intermittent  pyrexia.  Later  in  the  disease  the  ansemia  becomes  profound, 
cedema  of  the  subcutaneous  tissues  takes  place,  and  often  there  are 
hfemorrhages. 

Two  forms  of  leuksemia  are  distinguished,  the  mixed  form  in  which  the 
spleen  and  marrow  of  the  bones  are  mostly  involved,  and  the  lymphatic 
variety  in  which  the  lymphatic  glands  are  enlarged.  An  examination  of  the 
blood  may  solve  the  difficulty. 

Kanthack  gives  the  following  diagnostic  points  to  enable  the  two  varieties 
to  be  distinguished  from  one  another  and  also  from  Hodgkin's  disease  : 


Hodgki?is  Disease 

Red  corpuscles  slightly  di- 
minished. 

Hh  diminished. 

Slight  changes  in  the  red 
corpuscles. 

Only  moderate  leucocytosis 
due  to  an  increase  of  lym- 
phocytes and  perhaps  neu- 
trophile  cells. 


Spleno-medullary  Ancsmia 
Red  corpuscles  diminished. 

lib  diminished. 


Lymphatic  Leukcemia 
Red  corpuscles  diminished. 

Hb  diminished. 


Red  corpuscles  vary  in  size     Rarely    nucleated    red    cor- 


and  shape,  many  nucle- 
ated. 
Enormous  leucocytosis,  in- 
crease in  large  hyaline  and 
eosinophile  cells  ;  small 
relative  number  of  lympho- 
cytes. 


puscles. 

Enormous  leucocytosis. 

Great  increase  of  lympho- 
cytes, other  kinds  dimi- 
nished. 


Treatment. — Arsenic,  phosphorus,  cod  liver  oil  and  iron  are  the  most 
likely  drugs  to  be  of  use.  Mercurial  inunctions  over  spleen  and  glands  may 
be  tried. 


The  Hseiuorrhag-lc  Diathesis 

During  early  life  a  disposition  to  bleed  arises  under  many  different  con- 
ditions. In  some  cases  the  disposition  to  bleed  is  hereditary,  in  others  it  is 
the  result  of  many  different  forms  of  illness.  We  will  consider  the  hereditary 
variety  first. 

Haemophilia. — This  term  is  applied  to  a  disposition  to  bleeding  which  is 
hereditary  ;  it  affects  males  more  often  than  females,  but  the  females  often 
appear  to  transmit  this  tendency  to  their  sons.  This  tendency  to  bleed  may 
only  appear  in  one  or  two  members  of  a  family,  the  rest  escaping,  but  those 
who  thus  escape  may  transmit  the  diathesis  to  their  children.  Haemophilia 
does  not  usually  appear  at  the  time  of  birth,  the  disposition  usually  first 
manifesting  itself  after  the  end  of  the  first  year  of  life.  It  is  true  that  newly 
born  children  are  apt  to  bleed  from  the  navel  or  suffer  from  haematemesis, 
but  this  is  the  result  rather  of  some  disease  than  from  inherited  tendencies. 


HczmorrJiagic  Diathesis  441 

Children  who  exhibit  this  diathesis  seem  to  exhibit  it  in  different  degrees  at 
different  times  ;  sometimes  they  appear  to  bruise  on  the  shghtest  injury, 
while  at  other  times  there  is  hardly  any  tendency  in  this  direction.  Purpura 
or  'bruising'  is  the  most  common  manifestation  ;  slight  pressure  or  a  slight 
knock  on  a  limb,  such  as  might  take  place  by  the  nurse  catching  firmly  hold, 
will  suffice  to  bring  out  a  well-marked  bruise,  which  is  many  days  in  fading. 
.Sometimes  a  number  of  htcmorrhagic  spots  make  their  appearance  spon- 
taneously, and  in  the  same  way  extensive  subcutaneous  bleedings  may  take 
place.  A  slight  scratch  or  cut  may  ooze  blood  for  some  time  before  it  stops, 
cracks  or  fissures  in  the  skin  of  the  lips  may  ooze  in  the  same  way.  Of  the 
mucous  membranes  perhaps  the  gums  most  often  bleed — friction  with  a  tooth 
brush  may  be  enough  to  start  a  ht^morrhage.  Epistaxis  is  also  very  common, 
and  may  be  very  difficult  to  stop.  There  may  be  haemorrhage  from  the 
stomach  from  straining  when  vomiting,  or  blood  may  appear  in  the  stools. 

Hasmaturia  also  takes  place  at  times.  Haematomas  of  the  scalp  are  liable 
to  follow  slight  falls,  or  injuries  and  bleedings  of  considerable  amount  may 
take  place  in  the  muscles  and  other  deeply  situated  structures.  Bleedings 
may  take  place  into  the  joints,  especially  the  knees.  It  may  be  the  result  ot 
injury,  but  in  some  cases  this  does  not  appear  to  be  the  case.  The  joints 
appear  swollen  and  tender,  and  contain  fluid — the  fluid  gradually  disappears 
with  rest  ;  but  if  repeated  bleedings  occur  much  thickening  of  the  synovial 
membrane  with  overstretching  of  the  ligaments  and  nodular  swellings, 
resulting  in  distortion  and  more  or  less  permanent  crippling  of  the  joint,  may 
result.  A  joint  into  which  haemorrhage  has  once  taken  place  is  apparently 
likely  to  suffer  again.     We  have  seen  patients  lamed  for  life  in  this  way. 

We  have  also  met  with  a  case  in  which,  in  addition  to  haemorrhage  into 
joints  on  several  occasions,  bleeding  took  place  beneath  the  palmar  fascia, 
causing  great  pain,  and  a  somewhat  alarming  appearance  of  the  hand.  The 
blood  was,  however,  slowly  absorbed,  and  no  serious  ill  result  followed.  The 
history  of  the  patient  is  as  follows  : 

Hcsmophilia,  Effusion  in  Knee  Joint. — L. ,  a  boy  of  14,  was  first  seen  in  September 
1890,  with  Dr.  Massiah.  Tliere  was  no  history  of  hasmophiha  in  the  family.  At 
Christmas  1889  he  sprained  his  left  knee,  and  it  at  once  filled  with  blood,  and  has  never 
been  well  for  any  length  of  time  since.  The  left  leg  is  smaller  than  the  right,  and  is  said 
to  have  always  been  so.  When  seen  in  September  the  left  knee  was  enormously  distended 
with  fluid  blood,  and  was  a  good  deal  hotter  than  the  other.  His  brother,  who  was  seen 
at  the  same  time,  had  numerous  bruises,  and  one  ankle  contained  fluid  blood,  which  was 
becoming  absorbed  and  giving  rise  to  discoloration  of  the  adjoining  parts.  On  examining 
the  knee  thirteen  days  later  it  much  resembled  a  joint  the  subject  of  chronic  rheumatic 
arthritis  ;  there  was  thickening  of  bone  and  crackling  of  the  joint,  with  occasional  '  locking.' 
The  limb  could  not  be  fully  extended,  and  there  was  \  inch  shortening.  In  April  1892  he 
was  seen  again  ;  the  knee  was  again  swollen  after  an  injury,  though  not  to  the  extent  of 
the  former  attack. 

Perhaps  the  most  serious  complication  of  all  is  a  cerebral  ha-'morrhage. 
This  may  be  the  result  of  a  blow  or  a  knock,  or  it  may  apparently  occur 
spontaneously.  Thus  a  girl  of  3f  years,  who  had  had  from  time  to  time 
bruise  marks  on  her  skin,  suddenly  developed  symptoms  of  paralysis  of  the 
respiratory  muscles,  and  she  died  asphy.xiated  in  three  or  four  days.  At  the 
post-mortem  a  hfemorrhage  into  the  medulla  was  found.  (See  case  under 
Medullary  H/emorrh.\ge,  p.  511.) 


442         Diseases  of  the  Blood  and  Blood-making  Organs 

The  prognosis  in  all  these  cases  of  heemophilia  is  necessarily  uncertain. 
They  are  carried  off  in  many  cases  by  intercurrent  disease,  to  which  they  fall 
an  easy  prey,  or  as  the  result  of  some  accident.  It  is  certain  that  some 
reach  adult  life,  as  examples  of  this  condition  are  not  uncommon  among 
adults. 

The  diagnosis  is  not  difficult  in  a  well-marked  case,  but  there  may  often 
be  a  doubt  as  to  whether  the  disease  is  hereditary  or  whether  it  has  super- 
vened on  some  form  of  disease,  but  in  the  hereditary  form  the  history  of 
bleeders  in  the  family  will  necessarily  be  of  help. 

Very  little  is  known  for  certain  about  the  pathology  of  these  cases.  It 
has  been  supposed  that  there  is  some  congenital  affection  of  the  arteries  or 
the  capillary  vessels,  which  allows  the  blood  to  easily  ooze  through  their 
walls,  but  this  has  not  been  substantiated.  We  must  be  content  for  the 
present  to  confess  our  ignorance. 

No  children  require  so  much  care  or  are  greater  causes  for  anxiety  than 
habitual  bleeders.  No  operation,  however  slight,  can  be  permitted  in  these 
cases.  Gum-lancing,  excision  of  tonsils,  drawing  teeth,  opening  abscesses, 
must  be  avoided.  They  must  be  carefully  watched  and  guarded  in  every 
relation  of  life.  When  bleeding  is  going  on  turpentine,  hazehne,  ergot,  and 
gallic  acid  are  the  most  likely  drugs  to  be  of  service.  Tr.  ferri  perchlor.  may 
be  applied  locally.  When  bleeding  has  taken  place  into  a  joint,  the  child 
should  be  kept  in  bed  with  the  affected  joint  fixed  in  a  splint  and  coohng 
lotions  applied.  After  a  week  of  rest,  if  no  recurrence  of  the  bleeding  takes 
place,  very  gentle  movement  and  rubbing  should  be  employed  to  prevent 
stiffness  and  favour  absorption  of  the  blood  as  perfectly  as  possible.  All 
violent  exercises  must  be  avoided  by  these  children  ;  they  are,  in  consequence, 
a  source  of  constant  anxiety  to  their  friends. 

Purpura  simplex,  Purpura  hsemorrhag-ica. — These  terms  are  applied 
to  conditions  in  which  the  hsemorrhagic  diathesis  has  been  acquired,  that  is,  is 
not  hereditary.  The  name  P.  simplex  is  applied  when  the  bleeding  is  sub- 
cutaneous only,  that  of  P.  heemorrhagica  when  the  bleeding  takes  place  from 
various  sources  besides  the  skm,  such  as  kidneys,  &c. 

Purpura  haemorrhagica  occurs  under  a  number  of  different  conditions. 
Thus  it  occurs  ( i )  in  malignant  smallpox  and  measles,  in  typhus,  occasionally  in 
scarlet  fever,  in  acute  ileo-colitis,  and  especially  in  diphtheria — in  these  cases 
it  is  no  doubt  due  to  the  presence  of  albumoses  in  the  blood ;  (2)  in  various 
ansemic  conditions,  especially  towards  the  later  stages,  when  the  anaemia  is 
severe,  such  as  scurvy,  pernicious  anaemia,  Hodgkin's  disease,  rickets  and 
syphilis ;  (3)  and  we  have  it  following  attacks  of  gastric  catarrh,  diarrhoea, 
croupous  pneumonia,  whooping  cough,  in  rheumatism  and  also  in  meningitis. 

It  occurs  at  times  without  being  associated,  as  far  as  can  be  made  out, 
with  other  diseases  ;  but  it  may  be  doubted  if  it  is  ever  an  independent  disease. 
In  most  cases,  at  any  rate,  some  other  disease  precedes  it,  and  it  seems  rather 
to  occur  as  the  result  of  changes  effected  in  the  blood  by  the  pre-existing 
disease. 

Purpura  sometimes  makes  its  appearance  as  a  mild  affection,  at  other 
times  it  is  acute  and  quickly  fatal.  Thus  a  child  may  present  itself  with 
large  and  extensive  ecchymoses  on  the  limbs  or  trunk,  but  it  is  not  in  the  least 
ill,  and  the  subcutaneous  bleedings  disappear  in  a  few  weeks  or  less.     Or 


Purpura  HcEviorrJiagica  443 

perhaps  a  child  is  seized  in  the  midst  of  apparent  health  with  ecchymoses 
and  severe  haemorrhages  from  the  kidneys  or  from  the  alimentary  canal  ; 
there  is  delirium,  and  then  coma  and  death  in  a  few  days.  Sometimes  purpura 
accompanies  a  type  of  disease  which  resembles  scurvy  more  than  anything 
else,  and  yet  there  has  been  no  deprivation  of  fresh  food  or  hardship  of  any 
sort.     As  an  example  of  this  we  may  relate  the  following  case  : 

Purpura  Hainorr/iagica. — Guy  F. ,  aged  six  years.  Was  always  a  fairly  healthy  boy 
till  .\ugust  1889,  when  he  had  a  severe  attack  of  diarrhoea,  with  collapse,  at  the  seaside. 
He  never  completely  recovered  himself,  being  pale  and  weak.  At  the  end  of  the  following 
Januar)'  he  suffered  from  spongy  gums,  occasional  vomiting  of  dark  blood,  and  frequent 
bruise  marks  on  his  body.  He  continued  much  in  the  same  state  for  the  next  month, 
when  (February  14)  he  tripped  and  fell,  striking  his  head  against  the  edge  of  a  table.  A 
hoematoma  of  the  scalp  quickly  formed  on  the  right  side  of  his  forehead  ;  during  the  same 
night  the  fingers  of  the  left  hand  twitched  continuously,  and  the  grasp  on  that  side  was 
feeble.  Next  day  the  grasp  of  his  left  hand  was  very  weak,  and  there  was  some  difficulty  in 
flexion  and  extension  of  the  wrist.  Four  weeks  after  the  accident  the  hsematoma  and 
bruising  had  nearly  disappeared,  and  power  had  mostly  returned  in  the  left  hand.  He, 
however,  continued  to  go  downhill,  there  was  pain  in  the  stomach  and  frequent  vomiting, 
oozing  of  blood  from  the  nose,  and  purpuric  spots  appearing  on  the  trunk  and  limbs.  A 
loud,  rough  bruit  was  heard  over  the  whole  heart  area,  he  became  more  and  more  anaemic, 
and  there  was  marked  wasting.  He  was  unconscious  for  20  hours  before  death,  which 
occurred  at  the  end  of  March.  Post-mortem. — Excess  of  clear  fluid  in  the  serous  cavities  ; 
punctiform  bleedings  on  surface  of  heart  and  lungs  ;  no  vahiilar  lesion ;  muscle  of  heart 
pale,  left  ventricle  dilated.  Stomach  much  dilated ;  walls  of  stomach  and  also  of  intes- 
tines very  thin.  Spleen  enlarged  and  soft.  Extensive  subarachnoid  haemorrhage  over 
surface  of  the  brain  ;  some  red  fluid  between  dura  and  arachnoid.  On  the  right  ascending 
frontal  convolution  is  a  haemorrhage,  circular  in  shape,  involving  the  width  of  the  convo- 
lution, extending  an  inch  into  brain  substance.    The  bleeding  had  involved  the  hand  centre. 

The  ecchymoses  which  occur  vary  much  in  size  and  number  ;  in  rare  cases 
the  greater  part  of  an  arm  or  thigh  is  of  a  dark  purple  colour  from  hccmor- 
rhage  beneath  the  cutis.  In  other  cases  the  purpuric  patches  vary  in 
size  from  mere  points  like  hsemorrhagic  flea-bites  thickly  scattered  over 
the  skin  to  patches  the  size  of  the  palm  of  one's  hand.  In  erythema  nodosum 
the  nodes,  which  are  first  of  a  rosy  tint,  become  in  a  day  or  two  purple  from 
capillary  haemorrhage.  In  rare  cases  patches  of  subcutaneous  haemorrhage 
become  gangrenous  ;  Sangster  has  recorded  such  a  case.  A  girl  of  5  years 
had  several  purpuric  patches  on  the  extremities  and  cheeks  ;  one  of  these 
on  the  arm  ended  in  gangrene,  recovery  eventually  taking  place.  Steffen  has 
collected  several  more  cases,  in  which  multiple  skin  gangrene  occurred  after 
purpura  ;  the  cases  proved  fatal. 

In  a  number  of  cases  hiEmorrhage  occurs  either  on  the  surface  or  into  the 
substance  of  the  brain.  We  have  already  referred  to  two  such  cases  coming 
under  our  notice,  one  in  which  there  was  medullary  haemorrhage,  and  the 
other  in  which  a  small  bleeding  occurred  in  the  Rolandic  area.  Grosz  (loc. 
cit.)  records  a  case  where  there  was  a  haemorrhage  the  size  of  a  nut  in  the 
substance  of  the  right  lobe  of  the  cerebellum,  and  also  beneath  the  piamater.' 
Steffen  has  collected  four  fatal  cases  in  which  meningeal  haemorrhage  or 
haemorrhage  into  the  brain  substance  was  ioViXi6.post  mortem.    In  some  cases 

1  See  Grosz,  Ueber  Purpura  im  Kinder  Salter :  Archiv  fiir  Kinderheilk.  Heft  i.  u.  ii. 


444        Diseases  of  the  Blood  and  Blood-tnaking  Organs 

there  has  been  evidence  of  brain  haemorrhage,  in  which  recovery  has  taken 
place.  Haemorrhage  has  also  been  found  in  the  substance  of  the  spinal 
cord. 

Steffen  reports  cases  in  which  a  myocarditis  occurred  in  the  course  of  pur- 
pura, leading  to  dilatation  of  the  left  ventricle  ;  and  a  consequent  inefficiency 
of  the  mitral  valves.  In  such  cases  a  mitral  murmur  will  be  heard  during 
life.  (See  case,  p.  443.)  Hiematemesis  is  not  uncommon.  Indeed,  vomiting 
is  frequent,  the  vomited  matter  being  streaked  with  blood,  probably  from 
punctiform  bleedings  taking  place  in  the  stomach.  Blood  in  the  stools  also 
occurs  in  these  cases,  and  punctilorm  bleedings  are  frequently  found  post 
viorteni.  Hsematuria  is  a  frequent  symptom  ;  in  some  cases  there  is 
albuminuria  and  no  blood  present. 

The  association  of  purpura  with  rheumatism  is  an  interesting  one.  Schon- 
lein  gave  the  name  of  Peliosis  rheumatica  to  a  form  of  purpura  in  which  the 
joints  were  affected.  Probably  Steffen  is  right  in  altogether  di"opping  the  name, 
inasmuch  as  the  so-called  Peliosis  rheumatica  is  purpura  in  which  there  has 
been  bleeding  into  the  joints  or  the  muscles  or  tissues  around  the  joints.  In 
true  rheumatism  purpura  does  occasionally  occur,  and  as  is  well  known 
Erythema  nodosum  occurs  in  association  with  rheumatism. 

As  a  rule  an  attack  of  purpura  is  feverless,  but  in  some  cases  there  is 
moderate  fever,  especially  before  the  appearance  of  a  crop  of  petechise.  In 
the  acute  cases,  such  as  have  been  described  by  Henoch,  Pye-Smith,  and 
others,  in  which  there  is  vomiting,  hsematemesis, hcematuria,  petechise,  delirium 
and  coma,  there  may  be  a  high  temperature. 

An  examination  of  the  blood  during  an  attack  shows  a  diminution  of  the 
hccmogloblin  and  of  the  red  corpuscles.  The  leucocytes  may  at  first  be  in 
slight  excess,  but  they  also  diminish  in  number.  Micro-organisms  have  been 
found,  but  as  yet  bacteriology  has  shed  but  little  light  on  the  pathology  of 
this  disease.  Experimentally,  it  has  been  shown  that  the  presence  of 
peptones  and  albumoses  in  the  blood,  give  rise  to  haemorrhages  and  many  of 
the  symptoms  of  purpura. 

QoTiC^rxiva^'CcL^  prognosis  \x\  purpura  little  can  be  said.  Purpuric  small- 
pox is  well-nigh  always  fatal,  and  purpura  occurring  during  the  course  of 
diphtheria  is  an  extremely  bad  omen.  In  malignant  scarlet  fever  and  also  in 
malignant  measles  the  rash  is  at  times  said  to  be  purpuric.  We  have  never 
seen  such  cases,  but  on  several  occasions  we  have  seen  the  rash  in  both 
diseases  assume  a  purpuric  appearance,  and  recovery  take  place  without  a 
bad  symptom.  In  some  forms  of  anaemia  with  wasting,  the  appearance  of 
purpura  marks  the  beginning  of  the  end.  Purpura  simplex  is  always  of  less 
grave  import  than  those  cases  in  which  heemorrhages  occur  from  internal 
organs. 

The  treatment  of  purpura  is  the  treatment  of  haemorrhage  generally. 
Among  the  most  valuable  haemostatics  are  turpentine  (TTLv-xx),  ex.  hamamelis 
liq.  (TT^v-lllxx),  ex.  ergotse  liq.  (iTLv-lTj^xx),  ergotine  by  subcutaneous  injec- 
tion, gallic  acid  (gr.  v-gr.  x),  and  acetate  of  lead  (gr.  \-%r.  i). 

Diseases  of  tbe  Retro-peritoneal  Glands. — There  are  a  considerable 
number  of  lymphatic  glands  situated  behind  the  peritoneum,  at  the  back  of 
the  abdomen  and  in  the  pelvis.  They  are  most  numerous  lying  along  the 
vena  cava  inferior  and  aorta  and  their  branches.     These  glands  may  become 


Retro-peritonccxl  Glands      '  445 

enlar^^ed  and  caseous  in  tubercular  disease,  or  may  be  the  starting  point  of  a 
lymphadenoma  or  abscess,  When  caseous,  they  are  so  in  association  with 
mesenteric  disease  ;  in  one  case  under  our  care  the  caseous  glands  surround- 
ing the  vena  cava  completely  compressed  the  latter,  giving  rise  to  oedema  of 
the  lower  limbs  and  enlarged  veins  on  the  surface  of  the  abdomen.  In 
another  case  a  lymphadenomatous  tumour  exactly  simulating  an  enlarged 
spleen,  which  had  commenced  in  some  retro-peritoneal  glands,  was  first  noted 
in  the  left  hypochondriac  region.  It  grew  to  an  immense  size,  occupying 
nearly  half  the  abdomen.  Some  of  the  more  obscure  forms  of  abdominal  and 
pelvic  abscesses  appear  to  originate  in  these  glands. 


44^  Syphilis 


CHAPTER   XXI 

SYPHILIS 

Infants  and  children  may  suffer  from  syphilis  acquired  in  various 
ways  after  birth,  or  they  may  be  the  subjects  of  hereditary  syphilis,  the 
virus  in  this  case  being  received  from  one  or  both  parents  during  intra- 
uterine life.  The  infant  may  be  inoculated  with  the  syphilitic  germ  at  the 
time  of  birth. 

Acquired  Syphilis. — Can  a  healthy  infant  be  syphilised  by  means  of 
the  milk  of  a  wet-nurse  ?  This  is  an  important  question,  and  one  which  is 
often  asked  by  parents  before  a  wet-nurse  is  employed  ;  there  is  no  evi- 
dence that  we  know  of  to  show  that  it  can,  and  there  is  a  strong  probability 
that  even  if  the  virus  was  present  in  the  milk  it  wouldnot  inoculate  the  infant 
unless  introduced  directly  into  the  blood.  That  the  infant  can  be  inoculated 
if  it  have  an  abrasion  on  the  lips  and  it  draws  blood  from  a  sore  nipple  of  a 
nurse  suffering  from  secondary  syphilis  is  certain,  and  it  may,  of  course,  be 
inoculated  by  the  discharges  from  the  genitals  of  the  nurse  conveyed  to  it 
on  the  nurse's  hands.  It  need  hardly  be  said  that  in  selecting  a  wet-nurse 
the  most  scrupulous  care  should  be  exercised  in  ascertaining  that  the  would- 
be  nurse  is  not  suffering  from  any  specific  disease  ;  a  careful  inquiry  must  be 
made  as  to  her  health  and  the  health  of  any  children  she  may  have  had, 
especially  with  regard  to  any  symptoms  of  syphilis. 

Childffen  of  various  ages  may  be  seen  in  dispensary  practice  suffering 
from  chancres  on  the  lips  and  genitals,  who  have  been  inoculated  from  their 
parents  or  others  having  specific  sores,  the  virus  being  perhaps  conveyed  on 
the  fingers.  It  is  important  to  bear  in  mind  that  not  only  are  the  discharges 
from  a  primary  sore  liable  to  inoculate, .  but  the  discharges  from  various 
secondary  lesions  both  in  acquired  and  hereditary  syphilis  may  also  infect. 
Thus  infants  suffering  from  coryza  or  specific  ulcerations  about  the  mouth 
may  inoculate  the  breast  of  a  healthy  wet-nurse,  though  they  apparently 
never  do  that  of  their  mother.  No  syphilitic  infant  should  be  wet-nursed  by 
any  one  except  its  mother.  It  must,  however,  be  stated  that  while  Colles 
relates  instances  of  syphilitic  infants  inoculating  their  foster-mothers,  many 
recent  writers  doubt  the  infectiousness  of  hereditary  syphilis,  and  in  many 
foundling  hospitals  on  the  Continent  wet-nurses  are  allowed  to  suckle 
syphilitic  infants  apparently  without  harm  resulting.^ 

The  symptoms  of  acquired  syphihs  in  children  are  the  same  as  those  seen 
in  adults.     There  is  a  chancre  followed  by  sore  throat  and  a  roseolous  rash. 

1  See  R.  W.  Parker,  '  Is  Inherited  Syphilis  Contagious?'  Edin.  Med.  Jour.,  Jtme  1896. 


Acquired  Syphilis — Hereditary  Syphilis  447 

But  as  Coutts  has  well  pointed  out,  the  rash  is  apt  to  be  scanty  and  evanescent, 
and  may  be  easily  overlooked,  while  subsecjuently  there  is  a  marked  tendency 
to  the  growth  of  condylomata. 

Syphilis  has  undoubtedly  been  on  rare  occasions  inoculated  by  means  of 
vaccination  :  abundant  evidence  of  this  exists  in  some  epidemics  of  syphilis 
which  have  occurred,  though  such  an  accident  is  exceedingly  rare.  It  may 
often  happen  that  when  vaccination  is  performed  it  is  followed  in  a  few  days 
or  weeks  by  symptoms  of  secondary  syphiHs,  such  as  aroseolous  rash,  coryza, 
&c.,  but  in  the  absence  of  a  primary  sore  at  the  seat  of  vaccination  these 
syphilitic  manifestations  cannot  be  accepted  as  evidence  of  vaccino-syphilis, 
and  evidence  may  most  probably  be  obtained  of  syphilis  in  the  parents 
or  in  some  of  the  brothers  or  sisters.  As  the  first  symptoms  of  hereditary 
syphilis  most  frequently  make  their  appearance  at  from  six  weeks  to  three 
months  after  birth,  and  as  this  is  the  usual  time  for  vaccination,  it  is  highly 
probable  that  vaccination  and  the  secondaries  will  often  exist  together  and 
yet  have  no  connection.  If  syphilis  has  been  inoculated  by  vaccination,  a 
month  or  six  weeks  later — during  which  time  perhaps  the  vesicles  have  im- 
perfectly healed — an  induration  makes  its  appearance  at  the  seat  of  one  or 
more  of  the  vesicles,  or  there  is  an  ulcer  with  an  indurated  base  which  has 
the  characters  of  a  hard  chancre  ;  this  remains  indolent,  crusts  over,  and  is 
followed  in  the  course  of  a  few  weeks  more  by  a  specific  eruption  and  other 
specific  phenomena.  In  any  case  where  vaccino-syphilis  has  taken  place  a 
well-marked  scar  is  left  at  the  seat  of  the  puncture  where  the  hard  chancre 
has  formed. 

It  is  important  to  remember  when  investigating  any  case  of  supposed 
vaccino-syphilis  that  an  interval  of  a  month  or  six  weeks  elapses  between 
vaccination  and  the  formation  of  a  chancre  at  the  seat  of  inoculation 
(Hutchinson),  and  the  diagnosis  of  syphilis  cannot  be  accepted  unless  this  is 
the  case. 

Hereditary  Sypbilis. — In  hereditary  syphilis  the  fcetus  receives  the 
poison  at  some  period  during  intra-uterine  life,  and  may  be  born  with  the 
evidence  of  syphilis  on  it,  or  it  is  born  healthy,  the  specific  symptoms  making 
their  appearance  within  a  few  weeks  or  months  of  birth.  In  these  cases, 
unhke  acquired  syphilis,  there  is  no  primary  sore.  The  part  played  by  the 
father  in  transmitting  syphilis  to  his  progeny  does  not  admit  of  a  doubt :  the 
more  recently  he  has  suffered,  the  more  hkely  is  he  to  transmit  it  in  a  severe 
form,  though  for  many  years  he  is  liable  to  beget  children  who  suffer  from 
hereditary  syphilis.  The  most  usual  way  in  which  he  transmits  it  is  by 
means  of  the  spermatozoa  at  the  time  of  fertilisation  of  the  ovum  ;  or  during 
the  intra-uterine  life  of  the  foetus  the  mother  may  become  infected  by  the 
husband,  and  she  may  infect  the  foetus  through  the  placental  circulation,  though 
this  appears  to  be  rare  during  the  later  months  of  intra-uterine  life.  The 
mother  may  transmit  the  disease  to  the  ovum  or  the  foetus  in  utero,  but  this, 
as  just  stated,  is  rare  after  the  seventh  month  of  foetal  life  ;  or  she  may  infect 
it  during  the  act  of  birth.  The  mother,  on  the  other  hand,  may  apparently 
be  infected  from  the  foetus,  though  often  she  appears  to  escape  ;  that  is,  a 
syphilitic  father  infects  the  ovum,  the  child  is  born  and  suffers  from  syphilis, 
the  mother  apparently  escaping  ;  but  the  escape  of  the  mother  is  more 
apparent  than  real,  inasmuch  as  such  women  appear  to  be  insusceptible  to 


448  Syphilis 

syphilis,  and  there  is  reason  to  beheve  that  they  do  not  escape,  though  the 
attack  must  certainly  be  slight.  This  was  very  definitely  laid  down  by  Colles, 
and  is  generally  known  as  his  law.  He  states  that  he  had  never  known  a 
syphilitic  infant,  although  sufifering  from  ulcerated  mouth,  infect  the  breast  of 
its  mother,  whereas  very  few  instances  had  occurred  to  his  knowledge  of  a 
hired  wet-nurse  escaping  under  the  same  circumstances.  Recent  writers, 
namely,  Parker,  Coutts,  Ogilvie,  have  brought  forth  evidence  to  show  that 
at  any  rate  Colles'  law  is  not  universally  true.  They  assert  that  inherited 
syphilis  is  but  slightly  or  not  at  all  contagious,  that  wet-nurses  are  not 
affected,  and  if  this  is  true,  it  will  explain  how  the  mother  escapes  without 
assuming  that  she  is  protected  by  a  previous  attack.  A  very  few  cases  have 
been  recorded  in  which  a  syphilitic  infant  has  apparently  infected  its  mother. 
It  would  certainly  seem  that  while  acquired  syphilis  in  infants  is  virulently 
contagious,  inherited  syphihs  is  but  slightly  so. 

The  following  is  a  summary  of  the  modes  of  infection  in  hereditary 
syphilis. 

1.  The  ovum  may  be  infected  by  the  spermatozoa  of  the  father  (paternal 
heredity). 

2.  The  ovum  may  be  infected  by  the  mother  (maternal  heredity). 

3.  The  ovum  may  be  infected  by  both  (mixed  heredity). 

4.  The  foetus  may  become  infected  by  the  mother  becoming  infected 
during  pregnancy. 

5.  The  mother  may  become  infected  by  the  foetus.  (Syphilis  by  concep- 
tion.) 

The  mixed  infection  is  the  most  serious,  and  the  more  recently  the  parents 
have  suffered  from  syphilis,  the  more  severely  will  the  infant  suffer.  In  four- 
fifths  of  the  fatal  cases  of  hereditary  syphilis,  the  infants  have  been  born 
within  three  years  of  the  parents  being  syphilised  (Fournier).  Syphilis  derived 
from  the  mother  alone  is  more  serious  than  syphilis  from  the  father  alone. 

Effects  of  the  Poiso7i  on  the  Fcetus. — The  mother  may  miscarry  at  any  time 
during  foetal  life,  a  result  due  to  disease  of  the  foetus  or  placenta  ;  this  is 
especially  likely  to  happen  if  the  father  and  mother  are  suffering  from  the 
disease  in  an  active  form.  The  exact  nature  of  the  lesions  is  uncertain  : 
the  placenta  and  internal  organs,  as  the  liver,  lungs,  &c.,  have  been  found 
diseased.  The  infant  may  be  born  at  term,  but  dead,  or  may  survive  its 
birth  but  a  short  time  ;  in  the  latter  case  it  is  puny,  shrivelled,  with  blue 
extremities  and  a  feeble  hoarse  cry.  It  may  suffer  from  various  skin  erup- 
tions, the  most  common  (in  the  newly  born)  being  pemphigus  ;  various 
internal  lesions  may  be  found,  such  as  interstitial  hepatitis,  and  there  may  be 
gummata,  perhaps  breaking  down,  in  the  thymus,  heart,  or  lungs.  It  may 
exhibit  a  tendency  to  bleed  (see  p.  34). 

Symptoms  and  Course. — The  first  definite  symptoms  usually  make  their 
appearance  during  the  second  month  of  life.  These  are  often  preceded  by 
more  ill-defined  symptoms,  such  as  restlessness,  fever,  peevishness,  diai-rhoea, 
and  dyspepsia.  The  infant  suffers  from  what  appears  to  the  friends  to  be  a 
cold  in  the  head  :  the  nasal  passages  are  obstructed  by  excessive  secretion 
and  the  infant  '  snuffles '  during  inspiration  ;  in  the  more  severe  cases  the 
breast  is  taken  with  difficulty,  as  respiration  is  impeded  during  sucking  on 
account  of  the  nose  being  blocked,  and  the  infant  has  to  stop  to  breathe 


Hereditary  Syphilis  '  449 

through  its  mouth.  The  coryza  is  followed  by  a  characteristic  rash,  which 
usually  consists  of  an  erythema  or  erythematous  patches  of  various  sizes, 
the  favourite  places  being-  about  the  anus,  genitals,  thighs,  and  forehead. 
These  patches  or  plaques  have  sharp  cut  edges,  are  dull  red  in  colour  and 
shiny.  Instead  of  an  erythema  the  rash  may  be  papular.  When  the  erup- 
tion appears  first  it  is  a  bright  red,  the  vividness  fades  in  a  day  or  two,  and 
the  skin  desquamates,  and  becomes  of  a  dull  red  or  coppery  hue.  As  the 
disease  progresses  the  secretion  oozing  from  the  nose  dries  up  and  forms 
scabs,  the  entrance  to  the  nostrils  becomes  sore,  and  perhaps  a  sanguineous 
purulent  secretion  escapes  from  time  to  time.  The  upper  lip  may  become 
e.xcoriated  and  scabbed  over.  The  corners  of  the  mouth,  which  are  con- 
stantly moist  from  the  excess  of  saliva,  become  raw  and  perhaps  ulcerated,  and 
fissures  and  scabs  may  form  which  heal  but  slowly,  leaving  radiating  scars 
(figs.  89,  90). 


'  Fig.  89. — Fissures  around  the  Mouth  in  a  case  of  Congenital  Syphilis. 
The  whole  appearance  of  the  face  is  characteristic. 

At  this  time  a  multiple  epiphysitis  frequently  occurs.  The  infant  cries 
when  it  is  handled,  and  the  ends  of  some  of  the  bones,  especially  the  lower  end 
of  the  humeri,  the  wrists  and  ankles,  are  found  swollen  and  tender  (see  fig.  93). 

The  mucous  membrane  of  the  larynx  may  be  affected,  becoming  swollen 
and  perhaps  ulcerated,  and  the  child  in  consequence  has  a  hoarse  cry  ;  there 
may  be  marked  anaemia  and  wasting,  so  that  the  child  emaciates  and  is 
reduced  almost  to  a  skeleton. 

Infants  occasionally  die  at  this  period,  apparently  from  the  intensity  of 
the  poison.  This  seems  to  have  been  so  in  the  following  case — owr  post- 
inortetn  notes  are  as  follows  (the  child  was  not  seen  during  life  by  any  medical 
man)  : 

The  mother  states  that  the  infant,  which  was  seven  weeks  old,  '  snuffled '  a  week  before 
its  death,  and  three  days  before  a  reddish  rash  appeared  on  the  buttocks  and  around  the 

G  G 


450 


Syphilis 


mouth.  It  was  found  dead  in  its  cot.  At  the  autopsy  the  infant  was  fairly  well  nourished, 
there  was  a  purulent  discharge  issuing  from  its  nose,  the  skin  around  the  mouth  and  nose 
was  excoriated,  apparently  from  the  nasal  secretion,  and  there  were  some  excoriations  and 
redness  around  the  anus.  The  whole  of  the  mucous  membrane  of  the  nose  was  in  a  foul, 
almost  sloughy  condition,  the  surface  being  dark-coloured  and  covered  with  muco-pus. 
On  one  tonsil  there  was  a  deep  ulcer  ;  there  was  no  laryngitis  ;  all  the  other  organs  in  the 
body  were  healthy. 

While  in  the  more  severe  forms  the  infant  is  the  colour  of  cafe  au  lait, 
wizened  and  wasted,  other  infants  may  be  seen  who  are  plump  and  ruddy, 
yet  who  are  undoubtedly  syphilitic,  and  who  subsequently  develop  a  typical 
rash.     In  some  who  suffer  later  from  syphilis  no  history  can  be  obtained  of 


Fig.  90. — Congenital  Syphilis,  showing  flattening  of  bridge  of  nose,  scars  around 
mouth,  and  keratitis. 

coryza  or  rash,  and  we  are  driven  to  the  conclusion  that  the  secondaries  are 
sometimes  so  slight  as  not  to  attract  the  attention  of  the  friends,  and  may 
even  deceive  the  medical  practitioner.  The  mortality  of  syphilitic  babies  is 
high  ;  not  only  is  the  effect  of  the  poison  depressing,  but  the  blood  seems  to 
be  profoundly  altered,  the  digestive  organs  are  interfered  with,  and  the  infant 
wastes  and  dies.  '  Conge^iital  sypJiilis^  '  nial-nutrition '  is  written  on  the 
death  certificate  of  many  syphilitic  babies. 

On  the  other  hand  those  who  suffer  in  a  less  severe  form  and  come  under 
treatment  early  rapidly  improve,  gain  flesh,  and  for  a  time  at  least  all  sym- 
ptoms disappear.  While  such  cases  may  apparently  be  entirely  cured,  yet 
like  the  secondaries  which  occur  in  adults,  the  symptoms  are  very  apt  to  re- 
appear, especially  during  the  second  and  third  years.  This  relapsed  syphilis 
may  make  its  appearance  in  children  in  whom  the  symptoms  following  birth 


Hereditary  Syphilis  451 

are  slight,  and  consequently  what  is  really  relapsed  syphilis  is  very  apt  to  be 
mistaken  for  acquired  syphilis.  This  recurrence  usually  takes  the  form  of 
condylomata  or  ulcerations  about  the  anus  or  tongue,  and  chronic  fissures 
about  the  corners  of  the  mouth  and  nose  ;  various  rashes  may  also  be  present. 
During  the  next  few  years  the  child  may  remain  fairly  well,  but  on  the 
approach  of  puberty  symptoms  which  correspond  to  the  tertinries  of  adults 
may  make  their  appearance.  Children  at  this  period  often  bear  the  marks 
of  past  lesions,  and  if  seen  for  the  first  time  there  may  be  no  difficulty  in 
recognising  them  as  subjects  of  congenital  syphilis,  as  their  flattened  noses 
and  the  linear  scars  at  the  angles  of  the  mouth,  and  typical  pegged  teeth, 
give  them  a  characteristic  appearance  (fig.  90).  They  are  apt  at  this  time  to 
suffer  from  periostitis,  caries  of  bone,  chronic  ulcerations,  ulcers  of  the 
mucous  membrane  covering  the  hard  palate,  which  may  involve  the  bone  ; 
ulceration  and  destruction  of  the 
soft  palate ;  various  affections  of 
the  eye,  as  iritis,  keratitis,  choroi- 
ditis ;  various  skin  diseases,  as 
ecthyma,  rupia,  &c.  ;  gummata  in 
the  superficial  structures,  and  also 
in  the  liver  and  other  internal 
organs.  Deafness  and  partial  de- 
mentia may  be  present,  the  latter 
accompanied  by  syphilitic  arteritis 
of  the  brain.  In  the  worst  cases 
the  child  may  suffer  for  years  from 
disease  of  one  or  other  of  the 
bones  (figs.  91,  92). 

Having  sketched  the  course  of 
the  disease,  we  may  now  proceed 
to  describe  some  of  the  phenomena 
presented  by  congenital  syphilis 
more  in  detail. 

Skin. — Pemphigus  is  one  of  the 
most  characteristic  of  the  syphilitic 
rashes,  and  when  present  at  birth 
may  be  taken  as  certain  evidence 
of  hereditary  syphilis.  The  seat  of  the  blebs  in  syphihtic  pemphigus  is  the 
palms  of  the  hands  and  soles  of  the  feet,  but  they  may  be  present  also  on  the 
extremities  and  trunk  ;  their  contents  are  purulent  or  sanguineous  ;  they  may 
be  succeeded  by  deep  ulcers.  According  to  Roger  non-specific  pemphigus  is 
rare  before  three  years  of  age  and  most  common  after  six  years  ;  the  blebs 
are  rarely  numerous,  do  not  occur  on  the  palms  of  the  hands  or  soles  of  the 
feet,  and  contain  serum  rather  than  blood  or  pus.  The  prognosis  is  bad  in 
syphilitic  pemphigus  if  the  infant  is  born  with  the  rash  ;  as  a  rule,  the  later 
it  appears,  the  better  is  the  prognosis.  The  commonest  rash  in  hereditary 
syphilis  is  a  roseola.,  which  may  take  the  form  of  a  bright-red  diffuse  rash 
with  a  sharply  defined  edge  surrounding  the  genitals,  with  perhaps  patches 
of  similar  redness  about  the  body  or  face,  or  there  may  be  roseolous  spots 
or  maculce  about  the  body,  with  a  more  diffuse  rash  on  the  soles  of  the  feet. 

G  G  2 


Fig. 


91. 


Complete  Destruction  of  the  Nose, 
Upper  Lip,  and  part  of  the  Jaw  in  Congenital 
Syphilis,  in  a  boy  aged  lo  years. 


452 


Syphilis 


The  eruption  is  at  first  a  vivid  bright  red  ;  in  a  few  days  it  fades,  becom- 
ing more  of  the  tint  of  lean  ham  ;  then  the  affected  part  desquamates, 
leaving  the  skin  smooth,  shiny,  and  dry.  The  rash  may  be  visible  for  weeks, 
assuming  in  its  later  stages  a  coppery  colour.  Instead  of  the  roseola,  the 
rash  may  consist  oi  papules  of  a  bright  red  colour,  which  are  confluent 
about  the  genitals  and  buttocks,  but  scattered  irregularly  over  the  body.  The 
rashes  most  likely  to    be  contounded   with  a  syphilitic  roseola  are  those 

so  commonly  present  about  the  geni- 
tals, especially  those  produced  in  in 
fants  with  diarrhoea  by  the  irritation 
of  faeces  and  wet  napkins.  The 
difficulty  of  diagnosis  is  only  likely 
to  arise  in  the  absence  of  a  charac- 
teristic rash  in  other  parts  of  the 
body,  or  of  coryza.  It  is  needless  to 
say  that  a  red  rash  with  excoriations 
and  signs  of  irritation  about  the 
anus  and  genitals  may  occur  in  both 
syphilitic  and  non-syphilitic  children, 
and  no  rash  in  this  situation  should 
be  regarded  as  specific  without  con- 
firmatory evidence  elsewhere.  Some- 
times the  '  napkin-rash,'  which  is 
present  about  the  genitals  and  folds  of 
the  knee,  takes  on  a  syphilitic  aspect ; 
there  are  small,  shallow,  kidney- 
shaped  ulcers  with  raised  mucoid- 
looking  edges.  Psoriasis,  or  scaly 
7'ashes,  vesicles, pustules,  a.ndecthyinay 
may  occur  in  syphilis,  in  infancy 
Simple  psoriasis  rarely  occurs  before 
the  third  or  fourth  year,  while  syphi- 
litic scaly  rashes  are  not  uncommon 
in  early  childhood,  on  the  plantar 
and  palmar  surfaces,  and  on  the 
face.  Pustules  followed  by  deep 
ulceration  are  not  rare  in  cachectic 
children  apart  from  the  effects  of 
syphilis  ;  thus  occasionally  in  chicken- 
pox  the  vesicles  are  succeeded  by 
pustules  or  bullae  and  a  deep  ulcera- 
tion is  produced.  In  making  a  diagnosis  several  points  must  be  borne  in 
mind  :  syphilitic  rashes  mostly  affect  the  genitals,  palmar,  and  plantar 
surfaces,  and  face  ;  they  are  usually  bright  red  at  first,  then  dull  red  and 
more  or  less  of  a  coppery  hue  ;  they  are  followed  by  free  desquamation,  and 
they  cause  no  itching.     Different  varieties  may  be  associated  together. 

Mucous  patches  and  condylomata  when  present  are  of  great  diagnostic 
value  ;  they  may  occur  at  all  ages,  but  are  especially  common  in  relapses 
in  children  two  or  three  years  old.     Their  common  seat  is  around  or  by 


Fig.  92. — Congenital  Syphilis.     Disease  of  bones 
of  upper  and  lower  extremities. 


Hereditary  Syphilis  '  453 

the  side  of  the  anus,  vulva,  fold  of  the  groin,  corners  of  the  mouth,  entrance 
to  the  nares— less  commonly  the  folds  of  the  neck.  They  form  where  there 
is  some  irritation,  where  a  surface  of  skin  is  fretted  by  some  discharge  and 
kept  constantly  moist.  Mucous  patches  may  be  present  on  the  side  of  the 
tongue  and  soft  palate.  We  must  not  forget,  however,  that  acquired  syphilis 
is  not  uncommon  in  children,  and  cases  seen  with  condylomata  may  be 
suffering  from  the  acquired  form  and  not  from  hereditary  syphilis. 

Corysa  is  perhaps  the  most  constant  symptom  present.  The  mucous 
membrane  of  the  nose  is  swollen  and  congested,  and  respiration  is  carried  on 
with  difficulty  on  account  of  the  obstruction.  The  infant  is  very  restless  at 
night,  waking  at  short  intervals  to  get  its  breath.  Later  on  a  purulent  dis- 
charge tinged  with  blood  makes  its  appearance,  which  frets  and  irritates 
the  skin  in  the  neighbourhood,  and  ulcers  and  crusts  form  along  the  upper 
lip  and  side  of  the  nose.  Caries  of  the  nasal  bones  may  take  place  ;  there 
may  be  a  discharge  of  pus,  which  makes  its  appearance  down  the  nose  and 
at  the  corners  of  the  eyes. 

Lesions  of  hiiernal  orgufts. — Parrot  has  pointed  out  that  an  ulceration 
due  to  syphilis  occurs  occasionally  near  the  median  line  inside  the  lower 
lip  ;  serpiginous  ulcers  occur  on  the  tongue,  inside  the  lips,  near  the  corners 
of  the  mouth,  on  the  gums  and  soft  palate  ;  they  are  mostly  shallow,  with 
a  red  and  shiny  base,  surrounded  by  a  raised,  whitish,  irregular  border. 
Condylomata  on  the  tongue  are  much  commoner  than  any  form  of  ulcera- 
tion. Deeply  cut  ulcers  make  their  appearance  on  the  hard  palate  in 
tertiary  syphilis,  the  bone  is  quickly  affected,  and  a  communication  with  the 
nasal  cavity  established.  A  deep  ulcer  may  form  on  the  soft  palate,  and 
shortly  a  sharply  cut  hole  be  seen  right  through  the  velum  palati.  Laryngitis, 
mucous  tubercles,  and  ulcerations  along  the  edge  and  at  the  base  of  the 
epiglottis,  occur,  but  specific  lesions  of  the  larynx  are  less  common  in 
children  than  in  adults.  Specific  lesions  of  the  lun^s  are  not  common, 
though  syphilitic  infants  frequently  die  of  broncho-pneumonia.  In  the 
lung-s  of  infants  born  dead,  or  dying  soon  after  birth,  gummata  and  fibroid 
indurations  may  be  found,  and  a  form  of  chronic  pneumonia  which  has  been 
described  as  white  hepatisation  by  Virchow.  Patches  of  white  hepatisation 
may  some.times  be  found  scattered  through  the  unexpanded  lungs  of  infants 
born  dead,  and  the  mediastinal  glands  may  also  be  enlarged  and  infiltrated 
in  a  similar  way.  The  gummata  are  most  often  seen  on  the  surface  of  the 
lung  and  are  apt  to  soften  in  the  centre  (Parrot).  The  liver  of  newly  born 
infants  may  be  enlarged  from  the  effects  of  interstitial  hepatitis.  Gummata  of 
the  liver  are  occasionally  found  in  infants  and  older  children,  but  they  are 
comparatively  rare.  Depressed  scars,  the  remains  of  gummata,  may  also  be 
seen.     (See  pages  187  and  188.) 

The  spleen  is  frequently  enlarged  and  indurated,  especially  where 
cachexia  is  a  marked  symptom,  as  pointed  out  many  years  ago  by  Gee.  It 
is  generally  simply  indurated,  but  gummata  have  been  found.  Dr.  G.  F. 
Still  records  a  case  of  a  boy  of  eleven  years,  in  whose  spleen  were  found 
gummata  from  \  in.  to  f  in.  in  size,  and  another  case  in  a  boy  of  six  years, 
the  spleen  was  found  enlarged  with  many  yellow  fibrous  masses,  varying  in 
size  from  a  pin's  head  to  a  horse-bean.' 

1  Path.  Soc.  Trans. ,  1897. 


454  Syphilis 

Lesions  of  the  brain  may  also  occur  especially  during  the  first  or  second 
year.  The  infant  suffers  from  eclampsia,  most  marked  on  one  side ;  the 
convulsions  perhaps  begin  in  one  hand  and  then  become  general,  they  are 
fi'equent  rather  than  severe.  Later  the  arm  gradually  becomes  paralysed 
and  spastic  ;  later  still  the  leg  of  the  same  side  is  affected  in  the  same  way. 
The  limbs  of  the  other  side  also  suffer,  and  the  infant  gradually  passes  into  a 
condition  of  dementia.  At  the  post-mortem  syphilitic  endarteritis  and 
softening  are  found.  Chronic  hydrocephalus  may  also  occur  in  syphilitic 
children.  Dementia  and  general  paresis  may  come  on  in  the  course  of 
syphilis  about  puberty  ;  gummata  of  the  brain  are  rare,  only  a  few  cases  are 
recorded  (Henoch,  Barlow).  Gummata  have  in  rare  instances  been  found  in 
the  kidney,  testes,  and  g-lands  (Fournier). 

Syphilitic  disease  of  the  bones  may  occur  both  early  and  late  in  the  dis- 
ease. Caries  of  the  nasal  bones  may  follow  the  coryza,  leading  to  the  falling 
in  of  the  nose  which  is  so  common  in  syphilitic  children  ;  or  the  bones  may 
be  completely  destroyed.  During  the  tertiary  period  caries  of  the  hard 
palate  and  turbinated  bones,  as  well  as  of  the  long  bones,  more  especially 
the  tibia,  may  occur.  In  the  latter  bone  caries  may  follow  periosteal  nodes  ; 
or  thickening  of  the  bones  may  be  met  with.  Apart  from  caries  a  peculiar 
inflammation  termed  syphilitic  epiphysitis  is  apt  to  occur  near  the  epiphyses 
in  the  long  bones  in  infants,  especially  at  the  lower  ends  of  the  humerus, 
femur,  radius  and  tibia.  The  mother  notices  that  the  infant  does  not  move 
an  arm  or  leg  so  freely  as  the  other,  and  it  screams  as  if  in  acute  pain  if  the 
limb  is  handled  or  moved  suddenly.  An  examination  of  the  end  of  the 
humerus,  if  the  arm  is  affected,  may  show  it  to  be  swollen  and  tender,  and 
the  limb  hangs  useless,  so  that  the  term  '  pseudo-paralysis  '  has  been  applied. 
(See  fig.  93.)  The  shafts  of  several  of  the  long  bones  perhaps  show  an 
enlargement  where  they  join  the  epiphyses,  and  sometimes  a  slight 
effusion  is  present  in  the  joint.  More  rarely  the  phalanges  of  the  fingers 
are  also  swollen.  The  nature  of  this  lesion  has  been  studied  with  great  care 
by  Wegner,  Parrot,  Taylor,  and  Kassowitz.  Separation  of  the  epiphysis 
from  the  shaft  and  the  formation  of  an  abscess  may  take  place,  though  in 
this  country  the  latter  accident  is  rare.  Lesions  in  the  cranial  bones  have 
been  described  by  Wegner  ;  he  found  gummatous  periostitis  of  the  dura 
mater  beneath  the  parietal  bone,  a  possibility  to  be  borne  in  mind  when 
epileptiform  attacks  occur  in  syphiHtic  children.  The  natiform  skull  belongs 
to  rickets  rather  than  syphilis  ;  a  hypertrophic  condition  of  the  bones  of  the 
forearm  and  leg,  giving  rise  to  a  marked  enlargement  of  the  shaft  of  the 
bones,  is  not  uncommon  (see  fig.  92). 

Cbronic  synovitis  of  the  knees,  wrists,  &c.  is  apt  to  occur  in  older 
children  (see  Diseases  of  Joints). 

The  teeth  of  the  second  or  permanent  set  are  often  misshapen  and 
peculiar.  The  most  characteristic  changes  are  seen  in  the  central  incisors 
of  the  upper  jaw  ;  they  are  more  or  less  dwarfed,  peg-shaped — i.e.  they  taper 
inferiorly — slant  towards  each  othei-,  and  have  a  central  notch  in  their  cutting 
edge  ;  the  other  incisors  may  be  more  or  less  dwarfed  and  notched. 

Affections  of  tbe  eyes  are  most  common  about  puberty,  the  commonest 
being  interstitial  keratitis,  iritis,  and  choroiditis.  The  two  former  usually 
occur  together,  though  they  may  occur  singly.     The  first  symptom  noticed 


Hereditary  Syphilis 


455 


IS  watering  and  irritation  of  the  corneal  conjunctiva,  then  a  steamy  appear- 
ance or  cloudiness  of  a  portion  of  the  cornea  :  this  is  followed  by  the  forma- 
tion of  minute  blood-vessels  on  the  surface  of  the  cornea,  giving  the  steamy 
patches  in  some  cases  a  reddish  or  salmon-coloured  tinge.  These  patches 
loin  the  sclerotic,  are  generally  symmetrical,  and  are  apt  to  relapse.  Dis- 
seminated choroiditis  may  occur  :  in  such  cases  small  patches  of  atrophy  of 
the  choroid,  of  a  white  or  grey  colour,  are  generally  seen  scattered  about 
the  fundus  of  both  eyes  ;  pigmentation  is  frequently  present  ;  there  is  often 
the  remains  of  a  past  retinitis  and  neuritis. 

Ears.— Gradually  increasing  deafness,  which  is  often  very  intractable  to 
treatment  and  depends  on  labyrinthine  mischief,  is  common  in  congenital 
syphilis.  It  usually  appears  at  about  the  same  age  as  interstitial  keratitis, 
i.e.  from  the  seventh  to  the  fifteenth  year,  but  occasionally  begins  much 


Fig.  93. — Swelling  of  lower  ends  of  Tibia  and  Fibula,  and  also  of  the  Radius  and  Ulna,  from  a 
syphilitic  infant  of  four  months  old.  The  swelling  lies  at  and  above  the  line  of  junction 
between  the  epiphyses  and  shafts.     (Compare  with  Rickety  Enlargement,  p.  201.) 


later.  Complete  deafness  frequently  results  from  this  affection.  The  three 
lesions  of  the  teeth,  the  cornea,  and  the  ear  are  known  sometimes  as 
'  Hutchinson's  triad '  of  symptoms,  and  may  be  looked  upon  as  quite  patho- 
gnomonic. Middle  ear  disease  is  also  sometimes  caused  by  congenital  syphilis. 
Diagnosis. — This  is  often  difficult  and  sometimes  remains  uncertain.  In 
the  infant  care  must  be  taken  not  to  mistake,  as  students  are  very  apt  to  do, 
an  erythema  about  the  genitals,  which  has  its  origin  in  the  irritation  caused  by 
fouled  napkins,  for  a  specific  rash,  or,  on  the  other  hand,  hastily  to  assume 
that  an  infant  is  not  syphilitic  because  there  is  a  certain  amount  of  excoria- 
tion and  rawness  about  the  anus  caused  by  the  fretting  of  the  wet  napkins. 
No  rash  can  be  taken  as  characteristic  which  is  not  present  in  other  places 
as  well  as  about  the  genitals,  out  of  reach  of  the  irritating  effect  of  the 
urine  or  faeces.  Coryza  in  an  infant  a  few  weeks  old  is  exceedingly  suspicious, 
especially  in  the  absence  of  signs  of  catarrh  of  the  bronchial  tubes  or  larynx. 


456  Syphilis 

and  if  it  remains  chronic  is  probably  syphilitic,  even  though  a  rash  may  never 
be  present.  Infants  may,  however,  suffer  from  acute  coryza  without  being 
syphilitic.  A  purulent  discharge  and  caries  of  the  nasal  bones  is  usually  syphili- 
tic. Tenderness  and  swelling  of  the  epiphyses  of  the  long  bones  in  an  infant  are 
strong  evidences  of  syphilis  ;  we  attach  no  importance  to  cranio-tabes,  or 
bosses  on  the  cranial  bones,  or  the  natiform  skull,  as  they  may  be  undoubt- 
edly present  in  rickets  and  perhaps  other  conditions.  Syphilitic  epiphysitis 
can  hardly  be  mistaken  for  the  enlargement  of  the  epiphyses  present  in 
rickets.  In  syphilis  the  swelling  is  situated  between  the  epiphysial  line  and 
the  shaft  (see  fig.  93),  while  in  rickets  the  swelling  involves  the  epiphysis 
itself  (see  fig.  30).  Syphilitic  thickening  occurs  in  infants  of  six  weeks  to 
three  months  old,  while  the  rickety  enlargement  is  rarely  seen  before  six 
months,  and  more  commonly  at  a  year  or  eighteen  months  of  age. 

Marasmus,  ansemia  with  enlarged  spleen,  and  eclampsia  may  all  occur  in 
infantile  syphilis,  but  in  the  absence  of  other  symptoms  we  must  be  very 
cautious  in  accepting  them  as  evidence  of  syphilis. 

Treatment. — In  all  cases  where  the  parents  are  known  to  have  suffered 
from  syphilis,  or  some  older  child  has  been  affected,  anti-syphilitic  treatment 
must  be  commenced  without  waiting  for  the  development  of  symptoms,  in 
the  hopes  of  mitigating  the  disease  or  of  preventing  its  development.  The 
anti-syphilitic  treatment  of  the  parents  who  have  had  syphilitic  children  forms 
an  important  part  of  prophylactic  management,  and  may  prevent  the  taint 
from  being  transmitted  from  the  mother  to  the  fcetus.  In  the  treatment  of 
infantile  syphilis  it  should  be  borne  in  mind  that  the  effects  of  the  poison 
are  apt  to  impair  the  functions  of  almost  every  organ  in  the  body,  and  in  the 
worse  cases  there  is  a  marked  tendency  in  the  direction  of  anaemia  and 
gastro-intestinal  atrophy.  The  dietetics  of  the  syphilitic  infant  require  the 
most  careful  attention,  especially  if  it  has  to  be  artificially  fed,  as  such 
infants  are  exceedingly  likely  to  suffer  from  aggravated  dyspepsia  and 
mal-nutrition.  It  should,  if  possible,  be  suckled  by  its  mother  ;  if  this  is 
impossible,  it  must  be  artificially  fed,  as  a  wet-nurse  is  not  permissible  on 
account  of  the  danger  of  her  becoming  inoculated  by  the  nasal  or  other 
discharges  from  the  infant.  As  soon  as  the  diagnosis  is  made  or  the  disease 
suspected,  mercury  must  be  given  in  some  form  or  other.  The  usual  plan 
is  to  give  mercury  and  chalk-powder  in  half-grain  doses  twice  a  day,  this 
form  of  mercury  being  used  on  account  of  its  mildness  and  its  being  less 
likely  to  disturb  the  bowels  than  calomel.  If  any  looseness  of  the  bowels 
follows  its  administration,  it  may  be  combined  with  a  grain  of  chalk  and 
opium  powder  or  the  compound  cinnamon  powder.  In  a  few  weeks  the  dose 
may  be  increased  from  half  a  grain  to  a  grain  :  this  treatment  should  be  con- 
tinued as  long  as  any  of  the  special  symptoms  are  present,  or  for  some  six 
weeks  or  two  months,  when  the  mercury  may  be  omitted  for  a  fortnight  or  so, 
and  the  syrup  of  iodide  of  iron  in  five  to  ten  drop  doses  may  be  substituted. 
If  there  is  much  cachexia  or  mal-nutrition,  a  few  drops  of  cod  liver  oil  may 
be  added.  Instead  of  the  mercury  and  chalk,  some  prefer  to  give  calomel 
in  one-sixth  to  one-half  grain  doses  combined  with  half  a^grain  of  saccharated 
carbonate  of  iron.  In  Vienna  a  combination  of  mercuiy  and  tannic  acid  is 
used  (hydrarg.  tannicum  oxydulatum)  when  other  mercury  salts  disturb  the 
bowels  ;  the  dose  is  the  same  as  calomel.      In  obstinate  cases,  especially 


Hereditary  Syphilis  457 

where  the  skin  eruptions  are  chronic,  sublimate  baths  as  recommended  by 
Baginsky  may  be  used  with  good  effect.  A  bath  may  be  taken  daily  in  which 
ten  grains  of  corrosive  sublimate  are  dissolved  ;  the  child  should  remain  in 
the  bath  some  five  minutes,  care  being  taken  that  none  of  the  water  gets  into 
its  mouth.  The  baths  are  more  cleanly  than,  and  preferable  to,  the  inunction 
of  blue  ointment,  and  act  with  greater  certainty.  During  the  time  the  infant 
is  taking  mercury  the  gums  should  be  carefully  watched,  and  any  signs  of 
stomatitis  or  sponginess  about  them  should  be  the  signal  for  at  once  dis- 
continuing all  forms  of  mercury.  It  is,  however,  very  rare  for  salivation  to 
occur  in  children.  The  coryza  should  be  treated,  when  the  obstruction 
or  secretion  is  excessive,  by  injections  of  weak  solutions  of  nitrate  of  silver 
(gr.  i  ad  3i)  or  boric  acid  ;  the  dried  secretion  should  be  removed,  and 
any  soreness  and  excoriation  about  the  nares  or  lips  should  be  smeared 
with  yellow  oxide  of  mercury  ointment,  which  may  be  applied  on  a  small 
camel's-hair  brush.  Boric  acid  may  be  applied  locally  as  a  dusting  powder 
to  the  rash  about  the  genitals  or  elsewhere.  During  the  relapses  mercury 
should  be  given  in  some  form  or  other,  and  the  mucous  patches  and  con- 
dylomata which  so  frequently  accompany  relapsed  syphihs  should  be  fre- 
quently dusted  with  finely  powdered  calomel.  In  the  later  stages,  during  the 
tertiary  symptoms  the  solution  of  bichloride  of  mercury  in  doses  of  half  a 
drachm  to  a  drachm,  combined  with  iodide  of  potassium,  should  be  given 
and  continued  for  many  months,  when  the  syrup  of  iodide  of  iron  may  be 
substituted.  Tertiary  syphilis  is  apt  to  be  very  chronic,  the  ulcerations  of 
skin  and  caries  of  bone  and  corneal  affections  remaining  for  months  nearly 
stationary,  and  quickly  relapsing  when  treatment  is  suspended.  Iodoform 
and  the  yellow  oxide  of  mercury  ointments  are  the  most  useful  local  appli- 
cations for  the  skin  and  conjunctiva,  while  a  solution  of  nitrate  of  silver 
(gr.  X  ad  3i)  may  be  used  as  an  appHcation  to  the  specific  ulcerations  of 
the  mouth  and  palate.  During  the  treatment  of  syphilis,  both  in  infancy  and 
later  childhood,  the  most  generous  diet  which  can  be  digested  must  be  pre- 
scribed. Abundance  of  fresh  air  and  change  must  be  insisted  on,  and  the 
most  scrupulous  care  taken  to  promote  cleanliness  and  to  prevent  any  non- 
syphilitic  individual  from  becoming  infected  by  any  discharges  from  the 
patient.   ' 

In  some  cases  of  late  congenital  syphilis,  healing  of  ulcers  or  bone 
lesions  will  only  be  procured  by  the  use  of  very  large  doses  of  iodide  of 
potassium,  either  alone,  or,  better  still,  in  combination  with  mercury.  We 
have  had  to  order  twenty-grain  doses  of  the  iodide  three  times  daily  for  a 
boy  of  about  twelve  before  any  material  improvement  was  effected.- 


458  Rheumatism 


CHAPTER  XXII 

RHEUMATISM — DIABETES   MELLITUS — DIABETES   INSIPIDUS 

Rheumatism 

Rheumatism,  either  in  its  acute  or  chronic  form,  is  not  common  during  the 
first  four  or  five  years  of  childhood  ;  it  is  commoner  after  this  age,  but  typical 
attacks  of  acute  rheumatism  occur  less  often  in  children  than  in  young 
adults.  Concerning  the  etiology  and  pathology  of  rheumatism  but  little 
need  be  said  :  hereditary  influences,  the  effects  of  cold  and  damp,  the 
retention  of  waste  products  in  the  blood,  and  the  poison  of  scarlet  fever, 
and  influenza  seem  in  greater  or  less  degree  to  predispose  to  or  excite  an 
attack  of  rheumatism. 

Scarlatinal  synovitis  has  been  fully  described  (p.  256)  ;  but  it  remains  to  be 
said  that,  during  convalescence  from  scarlet  fever,  attacks  of  what  appear  to 
be  true  rheumatism  occasionally  occur.  This  is  in  our  experience  more 
common  in  young  adults  than  in  children. 

Symptoms. — The  symptoms  in  older  children  closely  resemble  those  seen 
in  adults,  except  that  the  attacks  can  rarely  be  called  acute,  but  belong  rather 
to  the  category  of  subacute.  The  illness  sometimes  begins  with  vomiting 
and  chilliness,  but  more  often  the  first  thing  complained  of  is  pain  and 
tenderness  in  the  larger  joints,  which  may  become  red  and  more  or  less 
swollen.  The  commonest  joints  to  be  affected  are  the  larger  ones,  such 
as  the  knees,  ankles,  hips,  wrists,  and  shoulders  ;  these  are  rarely  all 
affected  at  the  same  time  or  indeed  in  the  same  attack  ;  much  more 
commonly  one  or  both  knees  are  distended  with  fluid,  while  subsequently  a 
wrist  or  an  ankle  becomes  red,  tender,  and  useless.  The  joints  of  the 
cervical  vertebrae  are  often  affected,  and  occasionally  some  of  the  smaller 
joints,  such  as  the  fingers.  There  is  not  often  much  fever,  the  temperature 
rarely  exceeding  102°.  Usually  there  is  not  much  sweating,  the  joints 
quickly  recover  themselves,  and  the  pain  and  immobility  disappear  in  a  few 
days.  Sometimes  the  only  evidence  of  a  rheumatic  attack  is  a  slight  redness 
and  tenderness  about  a  single  joint.  It  is  the  exceeding  mildness  of  these 
attacks  as  well  as  the  want  of  intelligence  to  localise  their  pains  that  make 
attacks  of  rheumatism  readily  overlooked  in  young  children.  A  crying  out 
when  disturbed,  with  a  certain  amount  of  paresis  or  immobility  about  a  limb, 
may  be  all  there  is  to  indicate  an  attack  of  rheumatism,  which,  mild  as  it 
may  be,  is  yet  perhaps  accompanied  by  endocarditis  which  may  inflict  a  life- 
long injury. 


Rheumatism  459 

Distinct  attacks,  however,  may  be  noted  in  young  children,  of  which  the 
following,  a  patient  seen  with  Dr.  Earle,  may  be  taken  as  an  example  : 

Acute  Rheumatism.  — A  little  girl  of  twenty-two  months  was  going  about  ns  usual  on 
March  22  ;  on  being  taken  up  the  next  morning  she  seemed  in  pain  and  was  unable  to 
stand,  complaining  (apparently)  of  her  left  ankle,  which  was  supposed  to  be  sprained. 
The  ne.xt  day,  however,  the  right  ankle  appeared  to  be  similarly  affected,  and  during  the 
succeeding  two  days  her  knees,  elbows,  and  neck  were  attacked  successively  in  the  same 
way.  On  the  27th  the  knee  joints,  especially  the  left,  were  considerably  swollen  and  hot 
with  fluid  in  the  joints  ;  the  next  day  both  joints  were  equally  enlarged.  The  general 
system  was  only  slightly  disturbed  ;  there  was  no  cardiac  affection.  The  knees  remained 
swollen  for  a  few  days,  but  gradually  recovered,  so  that  at  the  end  of  thirteen  days  she 
could  again  walk  a  little. 

In  most  attacks  the  child  becomes  antemic.  Children,  like  adults,  are 
liable  to  relapses  ;  usually  fresh  joints  are  affected,  with  the  symptoms 
attendant  on  the  primary  attack.  In  some  instances  the  attacks  are  of  a 
chronic  type.  Thus  stiff  neck,  or  torticollis,  as  the  result  of  the  joints  of  the 
cervical  vertebrse  being  attacked,  may  be  very  intractable,  and  the  condition 
suggests  caries  of  the  upper  cervical  vertebras.  However,  the  symptoms 
usually  disappear  with  a  few  weeks  in  bed,  with  the  head  fixed  between  sand 
bags. 

The  complications  and  manifestations  of  rheumatism  are  of  great  im- 
portance, but  they  are  all  overshadowed  by  acute  carditis,  and  it  is  the  danger 
of  cardiac  lesions  supervening  that  makes  us  look  with  so  much  care  and 
anxiety  at  all  joint  pains  in  children.  As  already  remarked  (see  p.  407)  it  is 
the  exception  for  children  to  escape  suffering  from  endocarditis  during  an 
attack  of  acute  rheumatism,  and,  moreover,  peri-endocarditis  may  supervene 
with  but  very  slight  joint  pain,  or  the  latter  may  come  on  later.  The  younger 
the  child  the  more  is  an  attack  of  acute  carditis  to  be  dreaded,  inasmuch 
as  the  mortality  is  high  in  the  very  young,  and  if  the  patient  survives,  it 
is  with  dilated  heart  and  damaged  valves.  As  already  pointed  out,  the 
pericardium,  muscular  walls,  and  endocardium  covering  the  valves  are  liable 
to  take  on  an  inflammation  when  under  the  influence  of  the  toxines  of  rheu- 
matism. The  heart  cavities  dilate,  the  pericarditis  notably  increases  the 
work  of  the  heart,  and  an  injured  mitral  also  puts  the  heart  at  a  disadvan- 
tage. The  chief  danger,  however,  lies  in  the  damage  to  the  muscular  walls 
themselves  ;  the  patient  goes  on  fairly  well  for  a  while,  then  cardiac  syncope 
gradually  supervenes,  and  in  a  few  hours  perhaps  the  child  is  dead.  Kpost- 
mortein  examination  shows  pericarditis  in  most  instances,  and  as  Drs.  D.  B. 
Lees  and  Poynton  have  demonstrated  morbid  changes  in  the  vessels,  interstitial 
tissues  and  muscle  of  the  heart-wall.  In  some  of  our  own  cases  which  were 
rapidly  fatal,  there  was  only  slight  pericarditis,  and  no  great  dilatation,  but 
the  muscular  wall  of  the  heart  was  friable,  pale  in  colour  and  mottled. 

Chorea  is  another  frequent  associate  of  rheumatism,  and  may  either 
precede  or  follow,  or  sometimes  actually  complicate,  the  rheumatic  attack. 
It  has  been  referred  to  elsewhere.  Pleurisy  andPleuro-pneumonia  occur 
at  times  as  complications  of  a  rheumatic  attack,  especially  when  pericarditis 
is  present.  Erythema  multiforme  and  TTrticaria  occasionally  occur  in 
connection  with  rheumatism  and  endocarditis.  The  erythema  may  take 
various    forms,  occurring   sometimes    as  irregular    patches    of  redness,    at 


460  Rheumatism 

others  as  red  or  white  papules.  Erythema  nodosum  is  not  uncommon. 
In  all  cases  where  such  forms  of  erythema  occur,  the  heart  should  be  care- 
fully examined.  Purpura  occurs  also  at  times  in  rheumatic  attacks. 
Peculiar  nodules,  first  described  by  Drs.  Barlow  and  Warner,  occur  in  some 
rheumatic  cases,  mostly  in  the  neighbourhood  of  joints.  They  are  subcu- 
taneous, the  skin  being  freely  movable  over  them  ;  they  are  most, common 
at  the  back  of  the  elbows  and  wrists,  at  the  ankles,  and  by  the  patelke.  In 
one  case  seen  by  us,  that  of  a  girl  suffering  from  severe  chorea  and  rheu- 
matism, there  were  several  hundreds  of  these  nodules,  many  of  them  being 
situated  over  the  bones  ;  friction  during  the  severe  movements  seemed  to 
act  as  the  exciting  cause.  They  were  present  at  the  back  of  the  scalp,  over 
the  spinous  processes,  along  the  edges  of  the  scapula,  and  along  the  ribs. 
They  are  not  painful,  and  vary  in  size  fron  a  split  pea  to  an  almond.  These 
nodules  are,  when  present,  associated  with  heart  disease  (see  case,  p.  520). 
Subacute  tonsillitis  is  not  uncommon. 

Diagnosis. — There  is  often  much  difficulty  in  distinguishing  the  synovitis 
which  accompanies  rheumatism  from  one  or  other  of  the  many  other  forms 
of  synovitis.  Thus  there  is  the  acute  suppurative  arthritis  of  infants,  the 
synovitis  of  septicaemia  and  scarlet  fever,  and  the  synovitis  which  is  apt  to 
go  on  to  effusion  and  has  a  chronic  course  which  chiefly  attacks  the  knees  ; 
there  are,  moreover,  the  rarer  arthritic  attacks  which  accompany  hccmophilia, 
syphilis,  gonorrhoea,  and  purpura.  It  may  be  impossible  definitely  to  say  if 
some  arthritic  attacks  are  really  rheumatic  or  not ;  their  subsequent  course 
may  possibly  clear  up  the  doubt.  In  infants  and  young  children  it  may  be 
difficult  to  localise  the  seat  of  pain  in  a  limb,  and  consequently  a  doubt  may 
be  raised  as  to  whether  in  a  given  case  where  there  is  pain  and  helplessness 
the  joints  are  affected  or  not.  Such  difficulty  may  arise  in  the  epiphysitis  of 
congenital  syphilis  and  in  the  tenderness  of  the  periosteum  and  haemorrhages 
which  are  associated  with  infantile  scurvy. 

Treat)iie?tt. — On  the  least  suspicion  of  any  joint  affection  in  a  child  it 
should  be  put  to  bed  between  the  blankets  and  restricted  to  a  milk  diet.  It 
is  a  comparatively  small  matter  if  we  are  over-cautious  in  our  treatment,  in 
keeping  at  rest  in  bed  a  child  who  has  but  slight  joint  trouble  and  who 
appears  to  the  friends  to  ail  little  ;  while  it  is  a  grave  matter  to  allow  a  child 
who  is  suffering  from  incipient  endocarditis  to  get  up  and  run  about,  or  to 
suffer  one  to  contract  endocarditis  in  consequence  of  getting  up.  Knowing 
the  readiness  with  which  peri-endocarditis  supervenes  in  mild  attacks  of 
rheumatism  in  children,  it  is  our  duty  to  warn  the  friends  of  this,  and  to 
insist  on  placing  the  heart  under  the  most  favourable  circumstances  by  giving 
it  as  little  work  to  do  as  possible.  This  is  best  accomplished  by  keeping 
the  child  at  rest  in  bed,  perhaps  for  several  weeks  after  all  pain  and  tender- 
ness have  disappeared. 

In  the  milder  cases  the  only  medicine  required  will  be  a  simple  saline 
such  as  citrate  of  potash  ;  the  affected  joints  should  be  painted  with  ex- 
tract of  belladonna  and  glycerine,  and  surrounded  with  cotton  wool.  A  small 
dose  of  Dover's  powder  may  be  given  at  night.  In  the  more  severe  cases 
where  many  joints  are  affected  and  there  is  much  fever,  salicjdate  of  soda 
should  be  given  ;  five  to  ten  grains  may  be  given  every  four  hours  to  children 
of  from  six  to  eight  years  of  age  for  two  or  three  days,  and  then  given  only 


Chronic  RJieumatism— Arthritis — Chronic  Arthritis     4.61 

every  six  hours  or  three  times  a  day  ;  it  may  be  prescribed  with  a  saHnc  or 
given  with  syrup  of  orange  peel. 

In  all  acute  or  subacute  cases  milk  is  the  best  form  of  food  ;  it  may  be 
given  in  combination  with  potash,  soda,  or  seltzer  water  ;  as  long  as  there  is 
any  fever  this  should  be  adhered  to.  There  is  always  a  risk  of  a  relapse  if 
beef  tea,  soup,  or  meat  is  allowed  too  earlj^  during  convalescence.  Arrow- 
root, rice,  and  custards  may  be  allowed  when  all  pain  has  been  absent  for 
several  days  and  the  temperature  has  been  normal  for  a  week. 

Cbronlc  Rheumatism. — Under  the  terms  chronic  rheumatism,  synovitis 
or  polyarthritis  are  a  certain  number  of  cases  of  doubtful  origin  and  patho- 
logy. In  a  few  instances  what  appears  to  be  true  rheumatism  has  a  chronic 
course,  and  certain  joints  are  swollen,  stiff  and  painful  for  many  weeks  or 
months.  The  ends  of  the  metacarpal  bones  and  first  phalanges  of  the 
fingers,  as  also  some  of  the  larger  joints,  become  enlarged,  deformed  and  stiff. 

In  syphilitic  cases  there  is  at  times  chronic  multiple  arthritis  coming 
on  about  puberty,  which  is  apt  to  be  persistent  in  spite  of  treatment.  In 
some  cases  thei'e  is  chronic  synovitis  with  efTusiop  in  both  knees,  with  no 
history  of  syphilis  or  rheumatism,  though  the  former  should  always  be 
suspected. 

Arthritis  deformans  or  Osteo-arthritis  occasionally  commences  during 
early  life,  mostly  about  the  age  of  puberty.  It  is  commoner  in  girls  than 
boys  and  in  those  who  are  weakly  and  ancemic.  The  attacks  usually  begin 
insidiously  with  stiffness  and  pain  in  the  small  joints  of  the  hand,  in  other 
cases  there  is  pyrexia,  pain  and  tenderness  of  the  joints,  which  subsides,  and 
later  on  is  followed  by  another  attack.  The  larger  joints  sooner  or  later  are 
apt  to  become  involved.  As  time  goes  on  the  joints  become  more  or  less 
deformed,  creaking  is  felt  on  movement,  and  permanent  ankylosis  takes 
place.  The  synovial  membranes  and  cartilage  of  the  joints  disappear,  the 
ends  of  the  bones  are  smooth  and  hard  with  osteophytic  growths  at  their 
margins.     Atrophy  of  the  muscles  acting  on  the  joints  takes  place. 

In  some  similar  cases  Heberden's  nodes  are  present.  These  are  small 
nodes  of  bone  on  the  distal  ends  of  the  second  phalanges  of  the  fingers,  and 
the  joints  are  apt  to  suffer  from  subacute  inflammatory  attacks.  Arthritis 
deformans  appears  but  little  influenced  by  salicylates.  Cod  liver  oil  inter- 
nally and  warm  dry  heat  externally  to  the  joints  are  the  most  likely  helps. 
Arthritis  deformans  is  closely  related  to  chronic  rheumatism,  or,  at  least,  is 
with  difficulty  distinguished  from  it  ;  in  some  of  our  cases  the  child  has 
suffered  from  repeated  attacks  of  subacute  rheumatism  especially  affecting 
the  fingers,  the  ends  of  the  bones  becoming  enlarged  and  the  joints  more  or 
less  stiff ;  there  has  also  been  endocarditis,  but  not  of  the  worst  type.  In 
one  case  of  ours  the  hips  became  stiff  and  distorted. 

Chronic  Arthritis. — Sarah  E.  L. ,  lof  years.  A  year  ago  began  to  walk  lame  and  her 
ankles  swelled.  She  went  to  bed  a  month  after  this,  and  has  been  bedridden  since.  She 
has  never  had  acute  rheumatism  or  chorea.  The  ankles  first  became  swelled,  since  then 
the  knees  and  wrists  ;  the  joints  were  at  first  stiff  and  extended,  later  they  have  become 
flexed.  She  is  an  anaemic  girl  and  very  thin;  both  wrist  joints  are  semi-flexed,  the  left 
especially  is  almost  ankylosed  ;  the  hands  are  thin,  the  fingers  tapering ;  there  is  much 
thickening  over  the  carpal  Joints.  The  hands  are  in  position  of  'main  en  griffe.'  The 
ankle  joints   are   also   very  immobile  and   the  bones  thickened.     The  knees  are   flexed 


462 


Rheumatism 


(?  subluxation),  swollen  and  fluctuating ;  extension  which  is  very  limited  causes  pain. 
Heart  and  lungs  normal ;  no  albumen  ;  there  is  much  muscular  wasting.  Attempts  were 
made  by  means  of  chloroform,  extension  and  splints  to  straighten  the  knees,  but  the  latter 
lapsed  again  into  the  old  position. 

Chronic  arthritis  ivith  g'landular  and  splenic  hyperplasia. — This 
form  of  arthritis,  which  has  been  especially  described  by  Dr.  G.  F.  Still,^ 
is  not  very  common  in  our  experience,  though  Dr.  Still  has  collected 
22  cases,  19  of  which  he  had   investigated   personally.     The  disease  may 

begin  during  the  first  three  or  four 
years  of  life,  and  is  specially  dis- 
tinguished by  a  progressive  effu- 
sion and  enlargement  of  the  joints 
with  hyperplasia  of  the  lymph 
glands  and  spleen.  The  enlarge- 
ment of  the  joints  differs  from 
osteo-arthritis  in  that  there  is  effu- 
sion into  or  around  the  joint,  with 
a  general  thickening.  There  is 
creaking  or  grating  as  in  osteo- 
arthritis. Where  the  joints  are 
swollen  there  is  no  pain  ;  in  some 
of  Dr.  Still's  cases  the  chil- 
dren became  bedridden  through 
chronic  flexion  of  the  joints. 
The  common  joints  to  be  af- 
fected are  the  wrists  and  knees, 
later  elbows,  ankles  and  fingers. 
There  is  muscular  wasting. 
The  most  remarkable  feature  is 
enlargement  of  the  glands  and 
spleen.  This  glandular  hyperplasia 
suggests  Hodgkin's  disease  ;  the 
axillary  glands  and  glands  in  the 
groin  and  posterior  triangle  of 
the  neck  are  most  often  affected. 
The  mesenteric,  hepatic,  and 
splenic  glands  may  also  be  en- 
larged. The  spleen  seems  con- 
stantly to  be  enlarged.  Anaemia  is  present,  and  there  is  periodical  pyrexia. 
The  course  of  the  disease  is  chronic.  There  seems  to  be  a  special  liabiHty 
to  pericarditis  and  pleurisy.  In  our  own  case,  we  were  suspicious  of  Hodg- 
kin's disease  on  account  of  the  enlarged  glands  and  spleen,  and  erratic  febrile 
attacks.  At  the  post-mortem  the  enlarged  glands  were  pale  and  by  no  means 
unlike  the  glands  seen  in  that  disease.  It  seems  unhkely  that  the  glandular 
enlargement  is  merely  secondary  to  the  arthritis,  but  what  the  connection 
is  it  is  not  possible  to  say. 

The  following  case  evidently  belonged  to  the  same  group  of  cases  as 
those  described  above  : 

1  '  On  a  form  of  chronic  joint  disease  in  children,'  Med.  Chi.  Trans.,  vol.  80. 


Fig.  94. — Chronic  Arthritis  with  Glandular  Enlarge- 
ment. The  dotted  lines  show  the  lower  limit  of 
the  liver  and  spleen.     Boy  aged  3  years. 


Chronic  Arthritis — Diabetes  Mellitus  463 

Joseph  M.,  aged  3  years,  was  admitted  to  the  Children's  Hospital,  November  2,  1896. 
The  mother  states  that  both  the  father  and  brother  have  had  rheumatism.  In  February  1896 
the  child  had  scarlet  fever  badly  ;  the  attack  was  followed  by  dropsy.  Three  months  after 
he  suffered  from  rheumatism,  a  number  of  joints  becoming  affected  at  the  same  time; 
they  were  painful,  but  are  not  so  now.  He  has  always  been  a  pale  child.  There  was  no 
history  of  syphilis.  On  admission,  it  was  noted  that  both  wrist  joints  were  puffy  and 
swollen,  having  a  pulpy  feel,  more  like  a  tubercular  joint  than  rheumatism  ;  both  knees  were 
also  swollen  and  flexed,  though  they  could  be  straightened  without  pain.  There  was  no 
pain  or  tenderness  in  the  joints.  The  glands  in  the  axilloe,  Scarpa's  triangle,  and  posterior 
triangle  of  the  neck  were  enlarged,  but  not  tender  (see  fig.  94).  There  was  well-marked 
enlargement  of  the  spleen  and  also  of  the  liver.  The  boy  was  pale  ;  there  were  2,700,000  red 
corpuscles  per  cub.  mill. ,  no  relative  excess  of  leucocytes  or  eosinophile  cells.  Heart  and 
lungs  normal,  urine  normal.  Temperature  erratic,  96°-io4°  F.  Fluid  withdrawn  from 
knee-joint  contains  leucocytes,  no  tubercular  bacilli.  November  6. — Slight  swelling  of  left 
elbow-joint.  December  2. — Temperature  continues  erratic  ;  some  evenings  it  rises  to  104°  ; 
joints  contain  less  fluid.  December  15.  —  Some  swelling  of  dorsum  of  right  foot.  Tem- 
perature erratic.  He  developed  broncho-pneumonia,  and  died  January  9,  1897.  The 
disease  had  existed  about  6  months.  Post-mortem. — Body  fairly  well  nourished,  very 
anaemic.  Knee-joints,  ankles,  elbows  contain  fluid,  thickened  synovial  membrane,  over- 
growth of  bone  and  cartilage ;  ends  of  metacarpal  bones  enlarged,  joints  contain  fluid. 
Axillary  glands,  glands  in  groin  and  neck  much  enlarged,  and  of  a  pale  colour.  Heart 
normal.  Lungs  broncho-pneumonic.  Mesenteric  glands  enlarged.  Liver  enlarged, 
glands  large  and  white  in  fissure. .  Spleen  enlarged,  5^  oz.,  indurated  glands  in  hilus  also 
large  and  white.     Kidneys  normal. 

Diabetes  ItXellitus 

Though  diabetes  is  much  less  common  in  children  than  in  young  adults, 
it  cannot  be  said  to  be  rare,  as  Gerhardt  has  recorded  1 1  r  cases  at  various 
ages,  from  six  months  to  fifteen  years.  Cases  have  been  observed  in  infants 
at  the  breast,  though  the  diagnosis  in  such  may  be  open  to  doubt  on  account 
of  the  difficulty  of  obtaining  the  urine,  and  of  the  uncertainty  of  detecting 
small  quantities  of  sugar  in  the  urine.  Little  can  be  said  about  the  etiology 
of  these  cases  ;  a  history  of  diabetes  in  the  family  may,  however,  often  be 
obtained.  Thus,  in  a  family  we  are  acquainted  with,  two  uncles  died  of 
diabetes,  and  two  children,  brother  and  sister,  aged  14^  years  and  3|-  years. 
Another  sister  of  6^  years  has  sugar  occasionally  in  the  urine. 

The  symptoms  noted  are  those  which  are  present  in  adults.  There  is 
the  harsh  dry  skin,  red  tongue,  marked  thirst,  and  voracious  appetite.  There 
is  often  incontinence  of  urine  on  account  of  the  large  quantities  passed.  The 
specific  gravity  of  the  urine  is  high,  1030  to  1040  or  more,  and  perhaps  5  per 
cent,  or  even  10  per  cent,  of  sugar  may  be  found.  The  child  usually  wastes, 
especially  if  not  carefully  treated,  and  is  apt  to  contract  a  fatal  pneumonia. 
Tuberculosis  or  chronic  phthisis  may  supervene  as  in  adults.  Diabetic  coma 
is  not  uncommon.  The  symptoms  commence  with  headache,  dry  tongue,  and 
dyspnoea,  followed  by  coma.  It  is  well  to  bear  in  mind  the  possibility  of  being 
called  to  see  a  child  who  has  rapidly  passed  into  a  state  of  coma  without 
diabetes  having  been  suspected. 

The  prognosis  is  mostly  unfavourable,  though  cases  are  recorded  which 
made  apparently  a  permanent  recovery.  In  the  fatal  cases  the  duration 
varies  from  a  few  weeks  to  a  year. 

Treatment. — All  starch-containing  foods  and  sugars  should  be  forbidden, 
gluten  bread  and  saccharin  being  substituted.     Milk  in  moderate  quantities 


464  Diabetes  Mellitus— Diabetes  Insipidus 

or  cream  may  usually  be  allowed,  as  children  are  much  more  dependent 
upon  milk  as  a  food  than  are  adults.  Beef  tea,  soups,  fish,  chicken,  and 
butcher's  meat,  with  gluten  bread  and  green  vegetables,  will  chiefly  form  the 
diet.  Much  difficulty  is  often  experienced  in  keeping  children  to  a  rigid 
diet,  as  they  long  for  bread-and-butter  or  puddings.  With  regard  to  drugs, 
codeia  (gr.  \  to  gr.  J)  or  opium  should  be  given,  while  the  bowels  are  carefully 
regulated  with  Carlsbad  salts  or  Rubinat  water.  Great  care  should  be 
exercised  to  prevent  the  child  catching  cold  or  any  of  the  zymotic  diseases, 
since  bronchitis,  whooping  cough,  or  scarlet  fever  is  almost  certain  to 
unfavourably  affect  the  course  of  the  disease. 


Polyuria — Biabetes   Insipidus 

The  etiology  of  this  condition  is  for  the  most  part  quite  unknown,  and  it 
probably  owns  a  variety  of  causes.  Cases  of  brain  disease,  of  contracted 
kidney,  tuberculous  kidney,  and  of  functional  diseases  of  the  alimentary 
canal  may  be  accompanied  by  polyuria.  In  the  majority  of  cases  no  cause 
can  be  assigned,  and  we  are  obliged  to  speak  of  such  as  idiopathic,  much  in 
the  same  way  as  we  speak  of  idiopathic  anaemia.  In  a  large  class  of  cases 
polyuria  is  temporary  only.  Children,  often  girls  between  three  and  six 
vears,  are  noticed  to  wet  their  beds,  or  make  water  in  the  day  time  far  more 
frequently  than  they  have  been  accustomed  to.  In  the  same  way  boys  will 
wet  their  trousers  frec^uently  during  the  day  when  it  was  thought  that  they 
had  grown  sufficiently  old  to  have  learnt  proper  habics.  An  examination  in 
such  cases  will  probably  show  no  abnormal  constituent  of  the  urine,  but  that 
it  is  of  low  specific  gravity,  perhaps  1005  to  loio,  and  passed  in  larger  amount 
than  usual.  Possibly  there  may  be  a  trace  of  albumen.  In  the  majority  of 
cases  this  condition  will  be  found  to  depend  upon  digestive  derangements  or 
improper  feeding  ;  it  appears  to  be  a  reflex  irritation  of  the  kidneys,  the 
source  of  irritation  bemg  in  the  intestine,  the  presence  of  an  intestinal  catarrh 
being  the  cause.  Possibly  also  the  deposition  of  uric  acid  salts  in  the  kidney 
may  be  the  cause  of  a  large  quantity  of  watery  urine  being  secreted.  The 
presence  of  thread  worms  or  round  worms  in  the  intestine  or  rectum  also 
appears  at  times  to  produce  polyuria.  In  those  rare  instances  of  contracted 
kidney  occurring  in  childhood  large  quantities  of  urine  are  sometimes 
passed  ;  in  such  cases  the  specific  gravity  is  low,  but  there  will  usually  be 
some  albumen. 

In  those  cases  to  which  the  name  of  '  Diabetes  insipidus '  is  usually 
applied  there  is  intense  thirst,  and  large  quantities  of  pale  urine  with  a 
specific  gravity  of  1002  to  1005  are  passed.  A  girl  of  8J-  years  under  our  care, 
who  had  suffered  for  some  six  months,  drank  as  much  as  ten  quarts  in 
twenty-four  hours,  and  passed  a  proportionately  large  quantity  of  water. 
When  restricted  to  ten  pints  of  fluid  daily,  she  would  in  the  night  crawl 
under  the  beds  to  the  bath-room  to  obtain  water,  or  surreptitiously  drink  her 
own  urine.  Such  patients  have  dry,  rough  skins,  are  aneemic,  and  of  irritable 
temper.  The  course  of  such  cases  is  exceedingly  chronic,  and  post-mortems 
are  seldom  obtained. 


Diabetes  Insipidus  465 

Treatment. — The  treatment  must  depend  on  the  cause.  If  simply  reflex, 
dependent  upon  intestinal  irritation,  a  calomel  purge  may  be  given  and  a 
carefully  restricted  diet  prescribed.  In  confirmed  cases  of  Diabetes  insipidus 
various  drugs  have  been  tried  :  opium,  strychnine,  valerian,  and  ergot  usually 
fail ;  in  our  own  case  no  drug  seemed  to  check  the  secretion  of  urine  in  the 
least — a  temporary  improvement  took  place  during  an  intercurrent  attack  of 
tonsillitis.  In  all  cases  the  patient  should  be  warmly  dressed  and  protected 
from  cold,  as  a  chill  has  the  effect  of  checking  the  perspiration  and  so  in- 
creasing the  secretion  of  urine. 


H  H 


466  Diseases  of  the  Nervous  System 


CHAPTER   XXIU 

DISEASES   OF  THE   NERVOUS   SYSTEM 

Introduction. — The  student  who  has  gained  his  knowledge  of  the 
diseases  of  the  nervous  system  entirely  among  adults,  Avill  be  certain  to  find, 
when  he  comes  to  see  the  same  class  of  diseases  among  children,  that  the 
difflculties  of  diagnosis  are  much  greater  in  the  latter,  and  that  some  diseases 
which  are  rarely  met  with  among  adults  are  common  enough  among  children. 
This  is  no  doubt  true  of  disease  in  children  generally,  but  it  is  especially 
true  of  the  nervous  system.  For  instance,  he  will  find  very  early  in  his 
career  that  it  is  often  exceedingly  difficult  to  estimate  the  amount  of  pain 
from  which  a  child  or  infant  suffers.  An  infant  or  peevish  child  will  cry 
from  fear,  discomfort,  or  bad  temper  just  as  loudly  as  from  the  severest  pain, 
and  it  may  be  quite  impossible  to  localise  the  seat  of  pain  or,  indeed,  to  find 
out  what  it  is  crying  for.  There  may  be  a  general  hyperaesthesia  present, 
but  it  will  be  mostly  very  unsafe  to  draw  any  conclusions  from  this  symptom 
alone  as  to  the  presence  of  organic  disease,  though  it  may  be  borne  in  mind 
that  hypergesthesia  is  frequently  present  in  the  early  stages  of  meningitis. 
The  infant's  legs  may  hang  down  helplessly,  and  he  may  at  first  think  that 
they  are  paralysed,  but  a  closer  examination  discloses  the  fact  that  there  is 
some  epiphysitis  or  periosteal  tenderness  which  prevents  the  child  from  using 
the  limbs.  On  account  of  the  readiness  with  which  reflex  disturbances  are 
evoked  in  the  young,  we  often  find  ourselves  in  difficulties  and  in  error.  Thus 
the  infant  has  one-sided  convulsions  ;  are  these  due  to  a  serious  lesion  on  the 
opposite  side  of  the  brain,  or  to  an  intestinal  catarrh  or  colic  ?  How  often 
the  differential  diagnosis  between  gastric  and  cerebral  vomiting  in  infants  is 
difficult  and  for  a  time  impossible  !  The  nervous  system  of  the  young  is 
easily  upset  by  a  high  fever  or  a  poisoned  condition  of  blood,  and  there  may 
be  drowsiness,  retraction  of  the  head,  and  convulsions — symptoms  which 
naturally  suggest  cerebral  disease,  such  as  meningitis. 

Among  the  diseases  which  are  much  commoner  in  the  young  than  in  the 
old,  meningitis  stands  pre-eminent,  and  assumes  in  consequence  a  position 
of  great  importance.  It  occurs  alike  in  apparently  healthy  and  robust 
infants  and  children,  and  in  those  whose  history  and  symptoms  suggest 
tuberculosis  in  some  of  its  phases.  Cerebral  hccmorrhage  from  a  ruptured 
artery  is  rare  in  the  young,  but  an  extensive  bleeding  may  take  place  on 
the  surface  of  the  brain  from  over-distended  veins  or  capillaries,  and  give 
rise  perhaps  to  a  lifelong  hemiplegia.  Convulsive  disorders — the  spasms 
being  local  or  general — are  vastly  more  frequent  during  the  first  two  or  three 


Clinical  Examination  467 

years  of  life  than  at  any  other  period,  and  their  results  much  more  serious. 
The  infant  may  die  in  a  convulsion  from  spasm  of  the  glottis,  or  a  meningeal 
haemorrhage  may  take  place,  and  a  serious  injury  to  the  brain  may  be  thus 
caused.  Among  other  diseases  which  are  of  greater  frequency  in  early  than 
in  later  life,  acute  atrophic  paralysis  and  chorea  may  be  mentioned. 

Clinical  Examination. — The  shape  and  size  of  the  skull  are  of  impor- 
tance as  giving  some  indication  of  the  size  and  configuration  of  the  brain. 
The  condition  of  the  skull  may  be  investigated  by  inspection,  palpation,  and 
mensuration  ;  neither  auscultation  nor  percussion  yields  any  indications  of 
much  practical  importance.  By  inspection  a  general  idea  may  be  obtained 
of  the  shape  of  the  head,  whether  large  fmacrocephalic),  small  (micro- 
cephalic), asymmetrical,  long  (dolichocephalic)  as  in  the  negro,  round 
(brachycephalic)  as  in  the  Mongols,  hydrocephalic,  or  sc^uare  as  in  rickets. 
By  means  of  palpation  the  condition  of  the  fontanelles  can  be  ascertained, 
whether  bulging,  as  in  hydrocephalus  ;  or  depressed,  as  in  anaemia  ;  or  widely 
open  for  the  child's  age,  as  in  rickets.  The  edges  of  the  bones  may  be  felt 
to  ascertain  if  they  are  thickened  ;  the  parietal  or  frontal  eminences  may  be 
unduly  prominent,  or  various  bosses  may  be  present,  as  pointed  out  by 
Parrot.  Undue  thinness  of  the  skull,  more  especially  of  the  occipital,  may 
be  detected  by  firm  pressure  with  the  fingers,  the  bone  being  felt  to  bend  or 
yield  beneath  the  fingers.  By  means  of  mensuration,  using  calipers  and  a 
thin  flexible  piece  of  lead  wire,  a  tracing  of  the  outline  of  the  skull,  both 
longitudinally  and  transversely,  may  be  made,  and  a  graphic  record,  thus 
made,  kept.  In  this  way  the  frontal  or  occipital  regions  may  be  shown  to 
be  smaller  than  normal,  or  one  parietal  region  may  be  flatter  than  the  other, 
as  in  some  cases  of  deficient  development  or  injury  at  birth. 

It  is  convenient  to  remember  that,  roughly  speaking,  the  average  circum- 
ference of  a  child's  head  is  14  in.  at  birth,  16  in.  at  six  months,  18  in.  at  a 
year  old,  20  in.  at  two  years,  21  in.  at  four  years,  and  after  this  the  increase 
is  slight.  At  twelve  or  thirteen  years  old,  2\\  in.  would  be  an  average.  We 
must,  however,  remember  that  there  are  large  heads  and  small  heads  without 
there  being  any  abnormal  condition  of  brain.  In  children  over  a  year  old  a 
head  measuring  17  in.  or  under  would  suggest  imbecility. 

The  clinical  examination  will  necessarily  include  observations  on  the 
condition  of  the  muscles  to  see  if  any  paresis  or  paralysis  is  present.  A 
slight  scjuint  is  easily  overlooked,  and  the  friends  may  have  to  be  appealed 
to  for  their  observations,  as  the  squint  may  be  present  at  one  time  and 
absent  at  another.  The  condition  of  the  pupils  must  be  observed,  and  it 
may  be  necessary  to  examine  the  optic  discs  and  to  test  the  refraction  of 
the  eyes.  If  there  is  any  question  of  paralysis,  the  child  should  be  examined 
when  naked,  and  if  it  can  walk,  the  character  of  its  gait  observed.  The 
condition  of  the  reflexes,  especially  the  knee-reflex,  and  the  presence  or 
absence  of  ankle-clonus  observed.  An  exaggerated  knee-reflex  with  ankle- 
clonus  is  usually  present  in  old  cases  of  '  birth  paralysis,'  and  in  pressure 
myelitis  when  the  disease  is  situated  above  the  lumbar  enlargement.  But 
these  phenomena  are  certainly  also  present  in  some  cases  of  hysterical 
paraplegia,  especially  when  the  paresis  has  lasted  some  time.  We  have 
twice  seen  exaggerated  knee-reflex,  both  times  in  boys,  following  an  ill- 
defined  feverishness  (possibly  influenza)  lasting  several  weeks,  and  finally 


4^^  Diseases  of  the  Nervous  System 

ending  by  completely  disappearing.  The  absence  of  knee-reflex  suggests 
peripheral  neuritis.  Ankle-clonus  is  also  seen  in  old-standing  disease  of  the 
tibia  when  the  leg  has  been  in  splints. 

Cerebral  Congestion. — A  passive  congestion  of  the  venous  system 
inside  the  skull  takes  place  whenever  respiration  ceases  or  is  impeded,  in 
consequence  of  an  over-filling  and  distension  of  the  right  side  of  the  heart. 
This  is  markedly  so  during  a  convulsion  and  in  acute  general  bronchitis. 
Does  an  acute  active  congestion  take  place  without  passing  on  into  an  acute 
meningitis  ?  This  question  is  difficult  to  answer.  Certainly  cases  occur 
which  suggest  this.  Thus  we  have  seen  school  children,  both  boys  and 
girls,  who  have  been  working  hard  at  examinations,  suffer  from  headache, 
vomiting,  prostration,  rigidity  of  the  muscles  of  the  neck,  squint — symptoms 
which  suggest  cerebral  irritation  or  an  early  stage  of  meningitis — recover 
entirely,  after  a  few  clays'  rest  in  bed,  under  the  influence  of  bromides.  We 
must  not,  however,  forget  that  any  symptoms  of  cerebral  irritation  in  the 
young  are  extremely  suggestive  of  a  miliary  tuberculosis  of  the  arteries 
of  the  brain,  which  may  be  followed  at  any  time  by  the  symptoms  of 
meningitis. 

IVienlng'itLs 

Tubercular  Alening-itis. — In  tubercular  meningitis  there  is  an  inflam- 
mation of  the  pia  mater,  set  up  by  the  presence  of  tubercles  on  the  vessels, 
more  especially  at  the  base  of  the  brain.  While  tubercles  and  meningitis 
are  very  commonly  found  associated  together  post  mortem,  it  must  be  borne 
in  mind  that  a  simple  or  non-tubercular  meningitis  is  not  uncommon,  and  also 
that  tubercles  may  be  present  on  the  vessels  without  any  meningitis,  though 
the  probabilities  are  great  that  if  tubercles  are  present  they  will  sooner  or 
later  light  up  inflammation  of  the  meninges.  Another  point  must  also  be 
remembered  :  that  a  meningitis  so  called  is  in  reality  a  meningo-encephaHtis  ; 
the  vessels  which  penetrate  the  grey  matter  of  the  convolutions  being  certain 
to  join  in  the  inflammation 

Tubercular  meningitis  is  less  common  in  children  under  the  age  of  one 
year  than  in  older  children  ;  simple  or  posterior  basal  meningitis  is  rela- 
tively more  common  at  this  period,  though  the  tubercular  form  certainly 
does  occur,  but  on  account  of  the  difficulty  of  distinguishing  between  simple 
and  tubercular  meningitis  in  infants  and  young  children  we  are  often  not 
justified  in  making  a  differential  diagnosis  in  the  absence  oi  2.  post-7nortem. 
Between  the  age  of  one  year  and  the  commencement  of  puberty  tubercular 
meningitis  is  a  common  disease. 

It  rarely  happens  that  the  pia  mater  is  the  first  part  of  the  body  to  be- 
come the  seat  of  tubercle  ;  a  tubercular  meningitis  is  in  the  large  majority 
of  cases  preceded  or  at  least  accompanied  by  grey  granulations  or  caseating 
tubercle  in  some  other  part  of  the  body.  A  tubercular  meningitis  is  often 
the  closing  act  of  a  general  tuberculous  process  ;  it  may  occur  early  or  late, 
and,  when  once  established,  quickly  brings  the  end.  T\i&  post-mortem  evi- 
dence of  this  is  clear  and  decisive,  for  in  the  bodies  of  those  dying  with 
tubercular  meningitis  grey  granulations  or  caseating  tubercle  will  almost 
certainly  be  found  either  in  the  lungs,  bronchial  glands,  brains,  spleen,  or  other 


Tubercular  Meningitis  469 

organs.  Clinically  the  same  thing  is  also  evident  :  children  suffering  from 
hip-joint  disease,  spinal  caries,  caseating  cervical  glands,  or  chronic  tuber- 
cular peritonitis,  are  not  infrequently  cut  off  by  an  intercurrent  attack  of 
tubercular  meningitis,  or  the  latter  follows  whooping  cough,  measles,  or 
pneumonia.  In  the  large  majority  of  cases  there  is  a  definite  history  of  ill- 
health  before  the  actual  brain  symptoms  supervene.  An  exception  to  this 
is,  however,  seen  in  the  case  of  infants  andjchildren  under  two  years  of  age, 
in  whom  occasionally  the  attacks  are  sudden,  supervening  in  the  midst  of 
apparent  health. 

What  determines  the  growth  of  tubercle  on  the  pia  mater  and  the  subse- 
quent meningitis  ?  No  certain  answer  can  be  given  to  this  question.  It  is 
easy,  and  perhaps  natural  enough,  to  attribute  it  to  over-excitement  of  the 
brain,  or  excessive  brain  work  ;  and  possibly  this  may  be  so  in  some  cases 
in  tubercular  children,  who  have  been  badly  fed  and  subjected  to  unfavour- 
able life-conditions,  while  their  brains  are  being  driven  at  the  highest  pressure  ; 
but  such  cases  must  be  exceptional.  It  must  be  borne  in  mind  that  tuber- 
cular meningitis  attacks  children  a  few  months  old  and  children  in  hospital, 
and  under  conditions  in  which  it  is  impossible  that  over-brain  work  can  have 
had  anything  to  do  with  the  supervention  of  the  meningitis.  We  cannot  say 
why  the  tubercular  process  should  in  one  case  attack  the  brain  and  in  other 
cases  the  peritoneum,  or  lungs,  or  spine. 

Symptoms  and  Course.  Premonitory. — The  onset  is  insidious  and  the 
early  symptoms  are  ill-defined,  being  those  of  general  malaise  rather  than 
of  actual  disease.  In  most  cases  there  is  a  history  of  ill-health  for  several 
months,  perhaps  succeeding  an  attack  of  measles  or  whooping  cough,  during 
which  time  the  child  has  wasted  or  lost  flesh  and  become  flabby.  There 
may  have  been  cough,  dyspepsia,  constipation,  loss  of  appetite,  otitis,  en- 
largement of  glands,  or  more  or  less  feverishness,  especially  at  night  ;  such 
symptoms  are  not  in  any  way  distinctive,  and  are  often  the  result  of  a  chronic 
intestinal  or  gastric  catarrh  :  yet,  if  there  is  a  family  history  v*'hich  suggests 
tubercle,  they  necessarily  excite  suspicion.  In  some  cases  definite  brain 
symptoms  precede  by  many  weeks  the  actual  attack  of  meningitis,  and  then 
perhaps  pass  away  or  remit  for  a  while.  Among  these  may  be  men- 
tioned headache,  squint,  a  staggering  gait,  an  unusual  tendency  to  fall,  a 
temporary  loss  of  control  over  the  sphincters.  The  late  Dr.  Oxley  records  a 
case  in  which  the  boy's  disposition  entirely  changed,  and  he  showed  a  constant 
tendency  to  bite  on  the  least  provocation  ;  often  there  is  extreme  irritability, 
which  is  all  the  more  suspicious  if  it  occurs  in  a  good-tempered  child.  Such 
symptoms  are  possibly  due  to  the  irritation  caused  by  the  presence  of  tubercles 
on  the  vessels  or  in  the  brain,  which  may  perhaps  precede  for  some  time  the 
attack  of  meningitis  ;  or  it  is  quite  conceivable  that  a  temporary  congestion 
or  even  a  patch  of  meningitis  may  be  present. 

It  is  impossible  during  the  premonitory  stage  to  do  more  than  suspect 
the  onset  of  tubercular  meningitis  or  tuberculosis  in  some  form  or  other  ;  in 
a  large  number  of  such  suspected  cases  recovery  gradually  takes  place  with- 
out any  definite  diagnosis  having  been  arrived  at  ;  in  these  cases,  however, 
we  are  hardly  ever  warranted  in  assuming  that  our  treatment  has  been  the 
means  of  warding  off  an  attack,  and  we  may  be  left  in  ignorance  as  to  its  nature. 
In  some  cases,  especially  in  infants,  there  are  no  preliminary  symptoms  :  the 


470  Diseases  of  the  Nervous  System 

infant,  while  in  apparent  health,  begins  to  vomit  and  gradually  becomes 
comatose,  or  almost  the  first  symptom  which  attracts  attention  may  be  a 
hemiplegia.  In  such  cases  a  simple  meningitis  is  perhaps  suspected,  but  the 
post-DwrteiJi  usually  shows  it  to  be  tubercular. 

The  premonitory  symptoms  gradually  pass  into  the  first  of  the  three 
stages  into  which  the  attacks  are  usually  divided — namely,  the  stage  of  excite- 
ment. At  the  commencement  of  this  stage  the  symptoms  may  be  chiefly 
gastric,  or  they  may  be  definitely  cerebral  from  the  first.  In  the  former 
case  the  most  prominent,  and  indeed  sometimes  for  several  days  the  only 
symptom,  is  vomiting.  This  may  begin  after  a  meal  and  be  attributed  to 
some  improper  food,  but  it  continues  in  spite  of  the  most  careful  dieting,  is 
usually  accompanied  by  a  clean  tongue,  and,  while  aggravated  by  food,  often 
recurs,  with  much  retching  and  nausea,  when  the  stomach  is  empty.  Too 
much  stress  must  not  be  laid  on  the  character  of  the  vomiting,  and  perhaps 
for  a  few  days  a  doubt  may  be  entertained  as  to  its  true  nature,  whether  due 
to  cerebral  disease  or  gastric  irritation.  The  vomiting  of  meningitis  is  usually 
erratic,  coming  and  going  without  any  apparent  cause.  At  this  stage  the 
child  may  be  perfectly  intelligent,  and  no  direct  cerebral  symptoms  may  be 
present.  Constipation  is  usually  present  :  the  abdomen,  which  is  at  first 
rounded,  becomes  flabby,  and  later  retracted,  from  the  contraction  of  the 
intestinal  walls  which  takes  place.  Before  long  other  symptoms,  more 
directly  pointing  to  the  head,  become  developed.  There  are  headache,  giddi- 
ness, great  irritabilit}^,  intolerance  of  light  and  noise.  The  child  likes  to  be 
nursed  by  its  mother,  lies  on  her  lap,  and  resists  the  interference  of  others. 
Its  temper  has  completely  changed  ;  it  is  feverish  and  extremely  irritable. 

'  The  symptoms  may  be  more  definitely  cerebral  from  the  first,  and  the 
vomiting  may  not  be  a  prominent  symptom.  The  child  complains  of  head- 
ache, which  is  often  intense  ;  there  is  giddiness  and  staggering  gait  ;  its 
sleep  is  disturbed  by  dreams,  or  it  wakes  up  with  a  shrill  cry  of  disti'ess, 
often  of  a  piercing  character,  and  known  as  the  '  hydrocephalic  cry.'  The 
child  neglects  its  toys,  preferring  to  lie  quiet  and  undisturbed.  The  pulse  is 
usually  quickened,  the  temperature  raised  a  degree  or  two  at  night,  and  the 
tongue  becomes  coated  with  fur,  which  has  often  a  brown  or  yellowish  tinge. 
Remissions  are  apt  to  occur,  and  for  a  while  perhaps  the  little  patient  is 
again  himself,  bright  and  chatty,  and  ready  for  his  toys,  but  to  the  dis- 
appointment of  the  friends  the  old  symptoms  return  with  greater  intensity. 
So  far  the  symptoms  have  been  those  of  cerebral  excitement,  caused  in  all 
probability  by  the  inflammatory  congestion  of  the  pia  mater  which  is  present  ; 
following  this,  comes  the  stage  in  which  effusion  is  taking  place  and  the 
brain  functions  become  more  and  more  effaced. 

The  second  stage,  often  called  the  stage  of  transition,  is  marked  by  the 
commencement  of  drowsiness.  The  child  becomes  more  and  more  dull  and 
heavy  ;  it  is  no  longer  found  on  its  mother's  lap,  but  in  bed,  in  a  half-drowsy 
state.  It  likes  to  lie  quiet,  does  not  wish  to  be  disturbed,  and  if  roused  it 
answers  in  a  snappish  manner  and  then  curls  up  again  and  is  off  to  sleep. 
The  vomiting  now  is  usually  less  urgent  or  perhaps  ceases  ;  the  abdomen  is 
retracted,  the  bowels  confined.  The  pulse  is  usually  slower  than  in  the 
earlier  stages,  and  is  frequently  irregular  and  hesitating.*  Commencing  optic 
neuritis  may  be  observed,  but  the  child  in  this  stage   will   often  keep   its 


Tiiberailar  Meningitis  471 

eyes  spasmodically  closed,  so  that  observations  on  the  discs  are  rendered 
difficult.  The  edges  of  both  discs  appear  blurred  and  indistinct,  from  the 
presence  of  swelling  ;  the  veins  become  distended  and  tortuous,  but  the 
changes  are  never  so  marked  as  they  are  when  a  cerebral  tumour  is  present. 
The  intensely  cong"ested  and  swollen  discs,  with  various  minute  haemorrhages 
so  often  seen  in  other  forms  of  cerebral  disease,  never  occur,  possibly  because 
there  is  not  sufficient  time  for  these  extreme  changes  to  develop.  Miliary 
tubercles  may  be  present  in  the  choroid,  but  these — as  far,  at  least,  as  our 
experience  goes — are  chiefly  present  in  cases  of  general  miliary  tuberculosis. 
Various  other  phenomena  are  apt  to  supervene,  such  as  convulsions,  muscular 
twitchings,  paralyses,  and  spastic  contraction  of  the  muscles  of  the  neck  and 
back,  less  often  of  the  limbs.  The  convulsions  may  be  general  and  bring 
about  a  fatal  result,  especially  in  young  children.  The  paralyses  may  involve 
the  muscles  of  the  eye,  face,  or  limbs  of  one  side.  Some  retraction  of  the 
head  is  common  :  sometimes  it  is  so  extreme  that  the  back  of  the  head  comes 
in  contact  with  the  spine  ;  the  back  is  frequently  arched.  There  is  often  a 
spasmodic  contraction  of  the  masseters,  so  that  the  child  grinds  its  teeth, 
making  a  peculiar  and  unpleasant  grating  sound.     There  is  apt  to  be  incon- 


Fig.  95. — Tracing  of  Movements  of  Chest  Walls  from  a  case  of  Meningitis,  showing 
'  Cheyne-Stokes'  respiration.     (After  Landois  and  Stirling.) 

tinence  of  the  urine  and  fasces.  As  the  child  becomes  more  and  more 
drowsy  the  respirations  become  altered  in  character,  approaching  the 
'  Chejme-Stokes '  type — i.  e.  the  respiratory  movements  become  shallower  and 
shorter.  Until  they  cease  ;  then  a  distinct  pause  in  the  respirations  takes  place, 
to  be  followed  by  a  deep,  sighing  inspiration,  which  is  again  followed  by  a 
series  of  shallow  respiratory  movements,  or  the  pause  is  followed  first  by 
shallow  then  by  deeper  respirations,  as  in  fig.  95.  The  pause  in  deep  coma 
may  last  for  several  seconds  ;  we  have  once  or  twice  timed  an  interval  often 
seconds. 

From  a  condition  of  drowsiness  the  child  passes  into  the  third  stage ^  or 
stage  of  coma.  It  can  no  longer  be  roused  01  recognise  its  friends  ;  the  con- 
junctivse  become  insensible,  the  pupils  dilated  and  sluggish,  and  the 
optic  discs  can  be  examined  without  difficulty.  The  muscles  of  the  limbs 
and  abdomen  are  weak,  flabby,  and  toneless.  The  tongue  is  coated  with 
a  thick  brown  fur,  and  sordes  appear  on  the  teeth  and  black  crusts  on 
the  lips  The  skin  is  harsh  and  dry,  and  the  wasting  extreme.  Excessive 
secretion  takes  place  from  the  conjunctivae,  so  that  the  eyes  are  smeared 
with  mucus  or  pus.  The  pulse  becomes  weak  and  rapid.  The  coma  is 
usually  profound,  so  that  the  child  cannot  be  roused  even  for  a  moment, 


4/2  Diseases  of  the  Nervous  System 

but  usually  the  power  of  swallowing  is  retained  to  the  last.  In  this  miser- 
able condition  the  patient  lasts  for  many  days,  perhaps  a  week,  and  even 
after  it  appears  moribund  slight  improvement  may  take  place.  The  total 
duration  of  the  disease  is  usually  about  three  weeks,  but,  especially  in  young 
children,  death  often  takes  place  much  sooner. 

The  temperature  throughout  the  course  is  most  uncertain,  but  always  o 
an  irregular,  intermittent  type,  sometimes  varying  three  or  four  degrees  during 
the  twenty-four  hours  ;  at  other  times  the  flights  are  much  less  marked.  The 
temperature  is  of  course  modified  if  there  is  an  extensive  tubercular  process 
in  progress  in  the  lungs  and  other  parts.  Hyperpyrexia  is  not  uncommon  ;  in 
one  case,  that  of  a  boy  of  three  years  of  age,  who  was  convulsed,  the  temperature 
rose  to  io8°  F.  (rectal  temperature)  shortly  before  death.  The  post-mortem 
showed  tubercular  meningitis,  caseous  mediastinal  glands,  and  some  miliary 
tubercles  in  the  spleen  and  kidneys.  The  lungs  were  free.  The  paralyses 
which  are  apt  to  occur  are  seldom  marked,  often  only  temporary,  being  rather 
paresis  than  paralysis ;  sometimes,  however,  when  extensive  softening  takes 
place  in  one  hemisphere  from  thrombosis  of  some  large  vessel,  the  paralysis 
of  an  arm,  or  arm  and  leg,  may  be  complete.  Ansesthesia  is  rarely,  if  ever, 
present  ;  hypersesthesia  is  not  uncommon  in  the  early  stages,  but  more  as  a 
part  of  a  general  irritability  than  anything  else. 

Whilst  in  typical  attacks  the  various  stages  are  fairly  well  marked,  cases 
are  frequently  met  with  which  are  extremely  irregular,  the  typical  symptoms 
are  absent,  and  no  diagnosis  is  made  until  the  child  is  comatose  and  moribund. 
In  such  cases  the  symptoms  may  be  indefinite  for  a  week  or  two,  then  a 
marked  improvement  takes  place,  which  gives  hopes  that  our  diagnosis  of 
meningitis  is  incorrect,  then  suddenly  convulsions  and  coma  supervene  and 
death  speedily  occurs.  The  fact  that  a  remission  of  many  of  the  symptoms 
may  take  place,  the  child  being  decidedly  improved  for  a  while,  must  be 
constantly  borne  in  mind.  In  other  cases  the  course  is  short  and  sharp,  in 
this  respect  resembling  some  cases  of  simple  meningitis.  Thus,  for  instance, 
a  boy  of  eight  years,  who  came  of  a  tubercular  family,  attended  at  school  till 
April  23,  though  for  the  last  few  days  he  had  not  felt  well.  He  then  stayed 
at  home  on  account  of  cough  and  weakness  ;  he  began  to  vomit  on  May  3  ; 
the  next  day  he  became  drowsy,  gradually  passing  into  coma,  and  died  on 
May  8.  At  the  post-mortem  miliary  tubercles,  with  some  pneumonia,  were 
present  in  the  lungs  and  in  the  abdominal  organs  ;  there  was  also  tuber- 
cular meningitis,  with  much  fluid  in  the  lateral  ventricles  and  subarach- 
noid space. 

In  infants  of  six  m.onths  and  under,  the  symptoms  are  often  the  reverse 
of  characteristic  ;  the  infant  perhaps  vomits  food,  but  in  other  ways  appears 
quite  well,  and  the  vomiting  is  not  unnaturally  looked  upon  as  due  to  some 
gastric  irritation  ;  then  possibly  some  rigidity  of  the  muscles  of  the  neck  and 
slight  retraction  of  the  head  are  noticed,  and  it  gradually  passes  into  a  con- 
dition of  drowsiness  and  coma.  Muscular  twitchings  of  the  facial  muscles 
or  frequent  clonic  spasms  of  the  muscles  of  a  limb  or  arm  may  be  present. 
In  other  cases  the  infant  appears  to  be  '  teething,'  there  is  some  slight  fever 
and  restlessness,  but  nothing  to  indicate  cerebral  disturbance  ;  then  suddenly 
convulsions  come  on,  followed  by  hemiplegia,  and  perhaps  coma.  The 
state  of  the  fontanelle  is  often  a  help  in  diagnosis  in  doubtful  cases,  as  is  also 


Tubercjilar  Meningitis    '  473 

the  rigidity  of  the  muscles  of  the  neck  and  consequent  retraction  of  the  head. 
The  fontanelle  is  full  and  bulging,  and  in  the  later  stages  the  veins  on 
the  forehead  may  be  more  prominent  than  usual,  and  the  head  may  actually 
enlarge  from  the  presence  of  an  excess  of  fluid  in  the  lateral  ventricles.  The 
retraction  of  the  head  is  not  diagnostic,  it  occurs  in  cases  of  posterior  basal 
meningitis,  and  sometimes  it  appears  to  be  the  result  of  reflex  irritation  from 
the  pulmonary  and  abdominal  viscera.  It  occurs  also  in  otitis.  Posterior 
basal  meningitis  (see  p.  479)  is  a  commoner  disease  in  infants  under  six  months 
than  tubercular  meningitis,  and  a  differential  diagnosis  in  the  early  stages  is 
difficult. 

Prognosis. — As  soon  as  a  diagnosis  of  tubercular  meningitis  is  made 
there  is  little  hope  of  recovery.  In  any  case  the  hope  must  be  rather  that 
our  diagnosis  is  wrong  than  to  expect  a  permanent  recovery  to  take 
place  from  tubercular  meningitis.  Yet  undoubtedly  the  meningitis  pro- 
duced by  the  presence  of  tubercle  does  not  always  kill  at  once,  and, 
moreover,  in  any  case  there  is  the  hope  that  the  meningitis  is  a  simple  one 
without  the  presence  of  tubercle.  We  have  seen  at  least  three  cases — in 
which  there  was  good  evidence  to  show  that  the  patients  were  suffering  from 
tubercular  meningitis — recover  for  a  time  and  die  subsec|uently  of  a  second 
attack  or  of  a  general  tuberculosis  ;  one  of  these  cases  may  be  shortly 
referred  to. 

Tubercular  Meningitis.  Te^nporary  Recovery. — Mary  S. ,  aged  6f  years,  was  quite 
well  till  a  month  or  two  before  admission  to  hospital,  when  several  '  cold  abscesses  ' 
formed  on  her  legs  and  discharged.  Lately  she  has  had  headache,  been  giddy,  staggered 
in  her  gait,  and  rambled  at  night.  For  several  nights  after  admission  she  was  restless, 
and  screamed  with  pain  shooting  through  her  head  ;  an  internal  squint  was  noted  in  the 
left  eye ;  she  was  fairly  sensible  in  the  daytime,  but  complained  of  headache,  and  fre- 
quently passed  her  motions  under  her  ;  there  was  occasional  vomiting.  She  was  treated 
with  ice  to  her  head  and  complete  rest  in  bed,  and  bromides.  There  was  slight  optic 
neuritis,  which  gradually  subsided  during  her  stay.  She  gradually  improved,  and  was 
discharged  after  a  three  months'  stay,  apparently  quite  well.  She  was  readmitted  si.x 
months  after  with  undoubted  signs  of  meningitis,  and  died  after  a  fortnight's  illness. 
T\^Q post-mortem  showed  miliary  tubercles  in  the  lungs,  cheesy  nodules  in  the  liver,  recent 
tubercles  on  the  vessels  at  the  base  of  the  brain,  and  recent  lymph  ;  there  was  also  very 
distinct  fibrous  tissue  at  the  base,  as  if  resulting  from  a  past  inflammation;  the  inter- 
peduncular space  was  matted,  so  that  the  third  and  fourth  nerves  had  to  be  dissected  out 
and  cleaned  of  fibrous  tissue,  and  the  lobes  along  the  Sylvian  fissures  were  firmly  matted 
together.  The  history  of  the  case  and  the  post-mortem  appearance  made  it  clear  that  a 
recovery  had  taken  place  from  a  basal  meningitis  in  a  tubercular  subject. 

A  permanent  recovery  from  an  attack  of  tubercular  meningitis  means  in 
the  vast  majority  of  cases  a  recovery  from  a  general  tuberculosis — a  result 
which  is  improbable.  The  prognosis  becomes  bad  in  the  extreme  when 
the  patient  has  sunk  into  a  drowsy  condition  and  Cheyne-Stokes  respiration 
is  present,  though  several  days  may  elapse  before  the  end  comes. 

Diagnosis. — In  a  disease  which  begins  so  insidiously  and  assumes  such 
varied  forms  the  diagnosis  is  necessarily  difficult.  It  must  be  in  the 
experience  of  most  to  have  made  mistakes  in  diagnosis,  in  suspecting  the 
onset  of  tubercular  meningitis  when  the  patient  was  suffering  from  some 
dyspepsia  or  intestinal  catarrh,  and,  on  the  other  hand,  making  light  of  the 
anxieties  of  the  friends  when  subsequent  events  have  justified  their  fears.  As 


474  Diseases  of  the  Nervous  System 

regards  diagnosis  in  the  early  stages  too  much  stress  must  not  be  laid  on 
irritability,  grinding  the  teeth  at  night,  loss  of  appetite,  wasting,  and  sleep- 
lessness, as  these  may  be  symptoms  of  a  perfectly  recoverable  disease.  On 
the  other  hand,  sickness,  giddiness,  frequent  stumbling,  staggering  gait, 
temporary  squint,  loss  of  power  of  the  sphincters,  even  though  these  remitted 
after  a  while,  would  justify  grave  suspicions.  They  may  indicate  the  presence 
of  tubercle  or  some  irritation  of  the  brain,  which  may  be  quickly  followed  by 
definite  symptoms  of  meningitis. 

The  principal  errors  which  are  likely  to  be  made  may  be  summed  up  as 
follows  : 

1.  Mistaking  the  vomiting  of  meningitis  for  simple  gastro-intestinal  dis- 
turbance. This  is  a  very  common  mistake  in  the  early  stages  of  mening- 
itis ;  the  vomiting  of  meningitis,  like  the  vomiting  of  gastric  catarrh,  usually 
follows  the  ingestion  of  food,  but  it  may  also  follow  any  movement  of  the 
patient  ;  it  may  occur  when  the  stomach  is  empty  and  the  tongue  clean. 
The  vomiting  of  a  gastric  disturbance  mostly  ceases  after  the  stomach  and 
bowels  have  been  unloaded,  while  a  cerebral  vomiting  is  continuous  in  spite 
of  treatment.  In  any  case  of  causeless  vomiting  in  a  child  a  careful 
look-out  must  be  kept  for  more  definite  brain  symptoms,  such  as  con- 
vulsions, dilated  sluggish  pupils,  retracted  head,  and  retracted  abdomen. 
A  hesitating  or  intermittent  pulse  would  strongly  suggest  the  onset  of 
meningitis.  The  past  history  of  the  patient  is  often  important.  The 
vomiting  and  convulsions  present  at  times  during  dentition  may  be  a 
source  of  difficulty. 

2.  The  mistake  may  be  made  of  attributing  to  meningitis  symptoms 
which  are  due  to  the  presence  of  some  febrile  disorder  or  reflex  irritation.  A 
child  cutting  his  teeth  may  be  irritable,  feverish,  drowsy,  and  may  start  in 
his  sleep,  simply  from  the  effects  of  dentition  or  from  undigested  or  improper 
food  in  his  alimentary  canal.  The  sudden  onset  of  fever  is  against  men- 
ingitis, as  also  is  evidence  of  dyspepsia,  such  as  flatulence  and  colic  ;  the 
condition  of  the  gums  should  be  carefully  examined.  A  few  days  would 
decide  the  diagnosis.  The  diagnosis  between  typhoid  and  meningitis 
is  not  usually  difficult,  that  between  typhoid  and  acute  miliary  tuber- 
culosis being  often  much  more  so.  The  symptoms  presented  by  a  child 
sickening  for  typhoid  may  not  be  unlike  those  presented  in  the  early  stages 
of  meningitis  ;  vomiting,  however,  is  not  a  symptom  of  typhoid  :  the  fever 
present  and  the  condition  of  the  abdomen  would  usually  decide  the  diagnosis. 
The  possibility  of  a  simple  meningitis  occurring  in  the  course  of  typhoid  or 
pneumonia  must  be  borne  in  mind,  though  it  is  not  a  common  complication 
in  either  case. 

3.  At  the  end  of  certain  exhausting  diseases,  such  as  acute  diarrhoea, 
marasmus,  &c.,  in  infants,  cerebral  symptoms  due  to  arterial  ansemia  of 
the  vessels  of  the  brain  are  apt  to  arise,  such  as  convulsions,  coma,  con- 
tracted pupils,  convergent  squint,  &c.  This  condition  has  been  called 
'false  hydrocephalus.'  The  history  of  the  case,  the  depressed  fontanelle, 
the  almost  pulseless  condition  of  the  infant,  and  the  rapid  onset  and  course 
of  the  '  false  hydrocephalus,'  would  usually  distinguish  it  from  meningitis. 

The  differential  diagnosis  between  tubercular  and  non-tubercular  men- 
ingitis is  often  impossible.     A  family  history  of  tubercle  or  a  history  of  the 


Tubercular  Meningitis  475 

individual  having  suftered  from  caseous  glands  or  other  tubercular  manifes- 
tations, or  having  recently  suffered  from  whooping  cough  or  measles,  would 
naturally  favour  a  diagnosis  of  the  tubercular  variety,  as  would  also  an 
insidious  onset.  On  the  other  hand,  the  history  of  a  blow,  or  an  otitis,  or 
exposure  to  a  hot  sun,  and  a  stormy  onset,  would  favour  the  diagnosis  of 
the  non-tubercular  form. 

The  diagnosis  between  acute  meningitis  and  otitis  is  often  difficult,  and 
yet  it  is  of  the  greatest  importance.  The  relation  between  the  two  conditions 
is  somewhat  complex  :  a  meningitis  may  undoubtedly  arise  from  contiguity 
of  diseased  bone  in  the  ear  or  acute  suppurative  otitis  ;  a  purulent  meningitis 
may  exist  with  suppuration  in  both  tympanic  cavities,  or  the  latter  cavities 
may  contain  cloudy  fluid  only,  under  circumstances  which  make  it  probable 
that  the  meningitis  and  otitis  are  both  dependent  on  the  same  cause,  and  are 
not  related  as  cause  and  effect.  There  is  much  reason  to  believe  that  an 
acute  suppuration  in  the  middle  ear  may  closely  simulate  acute  meningitis, 
and  there  is  little  doubt  that  they  have  often  been  mistaken  one  for  the 
other.  Cases  which  have  been  diagnosed  as  acute  meningitis  have  quickly 
recovered  after  a  discharge  of  pus  from  the  ear,  either  bursting  through  the 
tympanic  membrane  spontaneously  or  being  relieved  by  incision.  In  cases 
of  double  suppurative  otitis  there  may  be  intense  pain  in  the  head,  fever, 
delirium,  convulsions,  optic  neuritis,  and  deafness.  The  point  of  greatest 
diagnostic  importance  is  the  deafness  without  facial  paralysis  ;  for,  as 
Cowers  points  out,  meningitis  '  never  gravely  injures  the  auditory  nerve 
without  the  adjacent  facial  nerves  ; '  nevertheless  the  diagnosis  between 
otitis  and  otitis  with  superadded  meningitis  is  exceedingly  difficult  and 
often  impossible. 

Morbid  Anatomy. — The  bodies  of  those  who  have  died  of  tubercular 
meningitis  are  usually  wasted  in  a  high  degree,  but  in  some  acute  cases  they 
may  be  fairly  nourished.  On  removing  the  skull-cap  and  exposing  the 
convex  surface  of  the  bram  the  veins  on  the  surface  will  be  found  to  be 
unusually  full  of  blood  ;  the  convolutions  are  flattened,  having  been  com- 
pressed by  the  distended  lateral  ventricles,  and  their  surfaces  are  dry  and 
sticky.  More  or  less  purulent-looking  lymph  is  jaresent :  it  may  be  usually  seen 
on  the  lateral,  less  often  on  the  convex,  surface.  On  examining  the  base,  the 
effusion  of  lymph  will  be  found  to  have  taken  place  much  more  freely  than 
on  the  convex  or  lateral  surfaces.  The  Sylvian  fissures  will  be  seen  to  be 
matted  with  lymph  ;  the  interpeduncular  space,  with  the  optic  commissures 
and  tracts,  the  third',  fourth,  and  eighth  nerves,  and  the  inferior  surface  of 
the  pons,  and  cerebellum^  will  be  found  in  the  same  condition.  Lymph 
may  generally  also  be  found  around  the  medulla  and  spinal  cord.  An 
examination  of  the  small  arterial  branches  will  show  that  they  are  studded 
with  minute  grey  or  yellowish  tubercles ;  the  lumen  of  some  may  be 
occluded  with  thrombi. 

In  some  cases  hardly  any  lymph  will  be  found,  but  the  arachnoid  is 
opaque  and  there  is  more  or  less  effusion  of  cloudy  fluid  beneath  it,  while 
the  brain  substance  is  oedematous  and  watery. 

Important  changes  are  also  present  in  the  lateral  ventricles.  The 
vessels  forming  the  choroid  plexuses  and  velum  interpositum  are  studded 
with   tubercles   and    besmeared   with    lymph  ;     the   lateral   ventricles   are 


476  Diseases  of  the  Nervous  System 

distended  with  fluid,  while  in  the  majoiity  of  cases  the  parts  around,  the 
corpus  callosum,  fornix,  and  optic  thalamus,  have  undergone  white  soften- 
ing and  may  be  washed  away  or  ragged  out  by  a  stream  of  water.  The 
presence  of  fluid  in  excess  in  the  lateral  ventricles  is  due  to  the  inflamma- 
tory processes  going  on  in  the  choroid  plexuses  ;  this  gives  rise  when  in 
excess  to  dilatation  of  the  ventricles,  softening  of  the  surrounding  parts,  and 
flattening  of  the  convolutions.  It  was  these  mechanical  effects  which  so 
struck  the  older  observers  like  Whytt,  who  overlooked  the  presence  of 
tubercles  as  the  primary  cause,  and  saw  only  in  such  cases  an  '  acute 
hydrocephalus '  or  '  water  on  the  brain.'  What  further  justisfies  these  older 
observations  is  that  in  some  cases  the  amount  of  lymph  is  very  small  and 
tubercles  are  found  with  difficulty,  while  there  is  much  subarachnoid  fluid 
as  well  as  distention  of  the  ventricles,  and  the  brain  substance  is  soft  and 
oedematous.  In  a  few  cases  large  tracts  of  the  superficial  or  central  parts  of 
the  brain  are  softened  and  diffluent,  the  brain  substance  being  yellow  or 
plum-coloured  from  the  presence  of  extravasated  and  altered  blood,  effects 
due  to  thrombosis  or  some  disturbed  condition  of  the  circulation.  A  micro- 
scopical examination  of  hardened  portions  of  the  grey  matter  will  show 
tubercles  and  efflision  of  leucocytes  around  the  capillary  arteries  which  enter 
the  surface  of  the  brain. 

How  do  the  symptoms  during  life  correspond  with  the  appearances 
found  after  death  ?  The  older  writers  were  probably  correct  in  ascribing 
the  excitement  during  the  first  stage  to  the  inflammatory  engorgement  of 
the  arterial  system  of  the  brain  ;  the  later  stages  of  drowsiness  and  coma 
to  the  effusion  of  fluid  into  the  lateral  ventricles,  which  gradually  compressed 
the  surrounding  parts  and  interfered  with  their  blood  supply ;  the  hemiplegia, 
paralysis  of  facial,  &c.,  to  the  softening  which  so  frequently  takes  place.  The 
retraction  of  the  head  and  stiffening  of  the  limbs  are  also  due,  we  are  in- 
clined to  think,  to  the  pressure  exerted  on  the  motor  tract  by  the  ventricular 
effusion. 

Other  tubercular  lesions  are  constantly  found  in  association  with  tuber- 
cular meningitis,  the  commonest  of  these  being  caseous  mediastinal  glands. 
The  lungs  also  are  rarely  free  from  tubercle. 

In  non-tubercular  meningitis  the  distribution  of  the  lymph,  which  is  often 
purulent,  is  less  exclusively  basal,  more  often  being  found  over  the  convex 
surface  and  between  the  hemispheres  in  the  longitudinal  fissure.  In  the  more 
chronic  cases  the  base  of  the  brain  and  cerebellum  may  be  adherent  to  the 
skull,  and  much  fluid  may  be  present  in  the  lateral  ventricles. 

Treatmeiit. — -The  prophylactic  treatment  of  tubercular  meningitis  is 
much  the  same  as  that  of  tuberculosis  generally.  All  children  who  are  so 
inclined  require  the  most  constant  care  in  all  the  relations  of  life.  Residence 
in  cities  must  be  prohibited,  and  country  or  seaside  life  insisted  upon.  A 
farmhouse  where  pure  milk  and  cream,  &c.,  may  be  had,  in  a  bracing  but 
not  too  bleak  situation,  may  be  selected  as  a  residence.  All  book  work  should 
be  stopped,  and  all  forms  of  excitement  be  strictly  prohibited.  The  diet 
should  be  carefully  regulated  ;  fats,  if  they  are  found  to  agree,  should  be 
taken  in  fair  quantities. 

The  child  should  be  warmly  clad  and  carefully  protected  from  changes 
of  weather.     The  bowels,  if  inclined  to  be  constipated,  should  be  carefully 


Tubercular  Meningitis — Simple  Meningitis  477 

regulated  with  hyd.  c.  cret.  or  rhubarb  and  soda.  The  sHghtest  suspicion 
of  cerebral  symptoms  should  be  met  by  putting  the  child  to  bed  in  a  darkened 
room,  giving  a  calomel  purge,  and  an  exclusively  milk  diet,  with  free 
administration  of  bromides.  One  or  two  grains  of  calomel  with  some  sugar 
may  be  given,  and  some  saline,  such  as  a  quarter  or  half  a  seidlitz-powder, 
the  following  morning.  Five  to  ten  grains  of  bromide  of  potassium  should 
be  given  every  four  hours.  The  vomiting  is  best  treated  by  purging 
smartly,  and  giving  peptonised  milk  prepared  with  Benger's  peptonising 
powders,  or  Savory  and  Moore's  tinned  peptonised  milk.  If  persistent 
vomiting  follows  the  ingestion  of  food,  all  food  must  be  stopped  by  the  mouth, 
and  Brand's  extract,  or  peptonised  milk  and  bromide,  given  by  means  of  an 
enema.  Nothing  is  gained  by  continuing  to  purge  after  the  initial  dose  of 
calomel  has  emptied  the  bowels  thoroughly.  If  there  is  much  cerebral  ex- 
citement, larger  doses  of  bromide  may  be  given  with  the  tincture  or  succus 
hyoscyami.  We  doubt  very  much  if  blisters,  setons  or  leeches  are  of  any 
service  in  tubercular  meningitis,  though  in  simple  meningitis,  if  the  excite- 
ment or  delirium  is  severe,  a  leech  applied  to  the  temples  will  certainly 
relieve.  Cold  to  the  head  is  of  undoubted  value  and  in  all  cases  should  be 
applied,  an  ice-bag  of  india  rubber  being  used  in  preference  to  any  other 
form.  Leiter's  tubes  form  a  convenient  method  of  applying  cold  to  the 
head,  and  they  can  be  used  where  ice  cannot  be  obtained.  Mercury  given 
freely  in  the  form  of  perchloride  is  of  all  drugs  the  one  most  likely  to  be  of 
service  in  simple  meningitis.  Iodide  of  potassium  is  frequently  prescribed, 
though  with  doubtful  advantage.  Drainage  of  the  subarachnoid  space  in 
cases  of  acute  tubercular  meningitis  has  been  carried  out  by  an  opening 
made  either  in  the  lumbar  or  cervical  spine,  or  preferably  by  trephining  the 
occipital  bone.  Successful  cases  have  been  recorded,  but  we  have  no  personal 
experience  of  the  method.  Operation  if  done  at  all  should  be  performed 
before  coma  sets  in. 

ITon-tuberculous  or  Simple  I^ening-itls. — -While  tuberculous  mening- 
itis is  by  far  the  commonest  form  met  with  during  early  life,  and  overshadows 
all  other  forms  by  its  importance,  yet  other  forms  are  also  met  with  which 
require  careful  consideration.  A  meningitis  occurs  at  times  in  association 
with  pneumonia,  summer  diarrhoea,  pysemia,  otitis,  scarlet  fever,  and  some 
other  of  the  infectious  fevers.  Presumably  in  these  cases  it  is  infective  : 
there  is  a  transference  of  cocci  or  other  organisms  from  the  lungs,  intestinal 
tract,  or  some  other  locality  to  the  membranes  of  the  brain,  and  inflammation 
set  up.  One  form  of  meningitis,  or,  rather,  cerebro-spinal  meningitis,  occurs 
in  widespread  epidemics,  though  it  is  comparatively  rare  in  this  country. 
xA.nother  form  which  is  also  due  to  the  presence  of  a  specific  organism  mostly 
affects  the  posterior  region  of  the  base  of  the  brain.  Meningitis  in  some 
instances  appears  to  be  due  to  exposure  to  the  sun  ;  in  other  cases  it  follows 
an  injury,  and  in  some  others  it  is  idiopathic,  or,  in  other  words,  no  cause  can 
be  assigned.     In  acute  septic  cases  it  is  mostly  purulent. 

Acute  Form. — In  some  cases,  both  in  infants  and  older  children,  the 
attack  may  run  a  very  acute  course,  death  from  convulsions  taking  place  in 
two  or  three  days.  The  acute  meningitis  in  some  of  these  cases  is  asso- 
ciated with  a  pleuro-pneumonia  or  peritonitis.  As  an  instance  of  rapid 
death  from  what  was  probably  an  acute  meningitis,  though  the  post-mortem 


47  8  Diseases  of  the  Nervous  System 

examination  showed  no   effused  lymph,  the  following  case  may  be  taken  as 
an  example  : 

Acute  Meningitis. — Beatrice  B.,aged  55  years,  was  a  healthy  child  till  six  months  ago, 
when  she  was  taken  with  pain  in  the  head,  fever,  and  vomiting,  but  recovered  in  a  day  or 
two.  Two  days  before  admission,  when  playing  in  the  street,  she  ran  in,  complaining  of 
pain  in  the  head,  and  vomited  ;  she  continued  to  vomit  constantly  for  two  da3's  ;  she  had 
a  fit  shortly  before  admission.  There  had  been  no  injury  to  the  head  ;  the  weather  was 
hot  at  the  time  (August).  On  admission  she  looked  ill,  her  face  having  an  expression  of 
anxiety :  two  hours  after  admission  she  was  convulsed  and  died.  Her  temperature  was 
not  taken.  At  the  post-mortem  all  the  organs  were  health3%  the  capillaries  of  the  brain 
were  intensely  injected,  and  there  was  much  clear  fluid  in  the  lateral  ventricles  ;  the 
arachnoid  membrane  was  somewhat  opaque. 

In  this  case  microscopical  examination  showed  that  the  capillaries  of  the 
meninges  and  grey  matter  of  the  brain  were  distended  and  gorged  with 
blood,  and,  though  it  cannot  be  certainly  assumed  that  this  congestion  was 
primary  and  inflammatory,  there  is  a  strong  probability  that  the  case  was 
one  of  acute  inflammatory  congestion  of  the  brain  and  membranes.  Similar 
cases  of  rapid  death  from  acute  hypersemia  of  the  brain  after  exposure  to  a 
hot  sun  are  recorded  by  Lewis  Smith  and  Soltman.  Henoch  mentions  a 
similar  case  in  a  girl  of  five  years,  the  attack  beginning  in  the  same  way 
with  headache  and  vomiting,  death  taking  place  within  forty-eight  hours, 
preceded  by  convulsions  and  coma.  At  the  post-mortem  a  purulent  exuda- 
tion was  present  on  the  convexity  and  at  the  base  of  the  brain. 

In  the  following  case  meningitis  supervened  on  acute  diarrhoea  : 

Acute  E?iteritis,  Meningitis. — Annie  B.,  aged  3^  years,  was  seized  with  vomiting  and 
purging  (in  August)  ;  the  next  day,  when  admitted,  she  was  in  semi-collapsed  condition. 
A  few  hours  afterwards  she  lapsed  into  unconsciousness.  She  was  delirious,  and  there 
were  muscular  twitchings.  Death  took  place  rather  suddenl}^  at  the  end  of  the  second  day 
of  the  illness.  At  the  post-mortem  the  pia  mater  was  intensel}'  congested,  the  arachnoid 
opaque,  the  S34vian  fissures  were  glued  together  with  lymph,  there  were  no  tubercles  ; 
there  were  patches  of  congestion  in  the  intestines  and  commencing  pneumonia  of  the  base 
of  the  right  lung. 

These  extremely  acute  cases  are  exceptional,  and  a  doubt  may  often 
surround  the  diagnosis,  as  acute  meningitis  in  the  early  stages  may  with 
difficulty  be  distinguished  from  the  onset  of  some  zymotic  disease,  as  scarlet 
fever  or  influenza,  or  perhaps  more  likely  of  pneumonia  ;  and  if  the  course 
terminates  early  in  a  convulsion  it  may  be  impossible  even  at  the  post- 
mortem to  say  with  certainty  Avhat  has  been  the  exact  nature  of  the  case. 
Death  from  a  convulsion,  accompanied  by  spasm  of  the  glottis,  gives 
rise  to  a  mechanical  engorgement  of  both  lungs  and  brain,  and  caution  is 
required  in  positively  asserting  that  an  early  meningitis  or  pneumonia  is 
present. 

In  the  majority  of  cases  acute  meningitis  runs  a  course  of  a  week  or  ten 
days,  the  symptoms  resembling  those  described  under  tubercular  meningitis. 
There  maybe  a  historj'  of  an  injury,  or  of  a  past  otitis,  or  of  exposure  to  the 
sun,  or  there  is  an  empyema,  pleurisy,  or  erysipelas.  The  early  symptoms 
are  those  of  intense  headache,  with  injection  of  the  conjunctivee,  vomiting, 
delirium,  strabismus,  and  often  high  fever,  perhaps  as  high  as  103°  to  105°. 
Later,  the  pulse  becomes  slow  and  hesitating,  the  abdomen  is  retracted,  the 


Posterior  Basal  Meningitis  479 

cervical  muscles  are  rigid,  and  Cheyne-Stokes  respiration,  coma,  and  various 
paralyses  ensue.  At  the  post-vior/ein  a  more  or  less  intense,  perhaps  puru- 
lent, meningitis  is  found  affecting  the  convexity  and  base  of  the  brain. 
Pneumococci  or  other  organisms  are  present  in  the  lymph  or  inflammatory 
exudations. 

Posterior  Basal  IMCening-ltis. — Basal  meningitis  is  for  the  most  part 
tuberculous,  but  there  is  a  well-marked  non-tuberculous  form  which  is 
limited  pretty  much  to  the  neighbourhood  of  the  pons,  medulla  and  cere- 
bellum, and  interpeduncular  space.  The  inflammation  is  subacute  or 
chronic,  adhesions  form  between  the  parts  gluing  them  together,  the  fourth 
ventricle  becomes  obliterated,  and  internal  hydrocephalus  takes  place  from 
blocking  of  the  aqueduct  of  Sylvius,  if  the  patient  lives  long  enough.  Infants 
are  usually  the  chief  sufferers,  but  older  children  are  sometimes  affected. 
The  most  prominent  and  often  the  earliest  symptom  is  cervical  opisthotonos  • 
this  varies  from  time  to  time,  the  muscles  of  the  neck  being  sometimes 
relaxed  ;  at  other  times  they  are  so  rigidly  and  completely  contracted  that 
the  neck  is  bent  and  fixed  at  right  angles  to  the  trunk.  The  rigidity  is  not 
confined  to  the  cervical  muscles,  but  the  muscles  of  the  back  and  lower 
limbs  are  in  a  state  of  spasm,  so  that  the  opisthotonos  is  general.  Vomiting 
and  convulsions  are  often  present  in  the  early  stages.  Drowsiness  and  fever 
are  mostly  present.  Squint  or  nystagmus  may  occur,  often  there  is  impaired 
or  complete  loss  of  vision,  optic  neuritis  is  absent.  There  may  be 
retraction  of  the  abdomen,  but  this  is  not  so  constant  as  in  tuberculous 
meningitis.  The  bowels  are  often  loose  or  normal.  The  course  of  the 
disease  is  chronic,  lasting  six  weeks  or  three  or  four  months,  though  the 
patient  may  be  cut  off  before  this.  In  the  later  stages — that  is,  if  the  patient 
survives — enlargement  of  the  head  takes  place,  as  the  result  of  an  internal 
hydrocephalus  caused  by  the  adhesions  formed  at  the  base  of  the  brain. 
There  may  be  hyperpyrexia,  as  in  the  case  related  below,  before  death. 
While  these  cases  are  usually  fatal,  they  are  by  no  means  always  so.  As  we 
have  said,  infants  are  most  often  attacked,  but  we  have  seen  similar  cases  in 
children  of  three  or  four  years  of  age  which  have  ended  in  complete  recovery. 
There  has  been  hyperpyrexia,  drowsiness,  extreme  opisthotonos,  the 
symptoms  lasting  for  a  week  or  ten  days  and  then  gradually  disappearing. 

As  already  stated,  ihe  post-vwrteui  findings  in  these  cases  include  lymph 
or  fibroid  adhesions,  according  to  the  stage  in  which  death  has  taken  place 
matting  together  the  interpeduncular  space,  pons,  medulla,  base  of  the 
cerebellum,  fourth  ventricle,  and  internal  hydrocephalus.  Dr.  G.  F.  Still 
has  shown  that  a  specific  organism  is  present  in  these  cases  ;  a  diplococcus, 
which  grows  readily  on  agar,  is  stained  by  methylene  blue,  but  not  by  Gram's 
method.  It  differs  in  many  respects  from  the  pneumococcus  and  the 
diplococcus  of  cerebro-spinal  meningitis. 

The  following  case  may  be  taken  as  an  instance  : 

Basal  Meningitis,  Hydrocephalics. — E.  P.,  aged  7  months  ;  no  historv  of  syphilis.  At 
6  weeks  of  age  had  an  attack,  during  which  he  was  always  crying  and  throwing  his  head 
back.  A  month  ago  he  became  drowsy  and  dull,  and  had  twitchings  of  right  arm  and  leg. 
He  is  unable  to  see.  Admitted  June  13.  Constant  vomiting  ;  abdomen  retracted  ;  limbs 
rigid  ;  toes  point ;  fingers  are  flexed.  From  June  13  to  June  25,  when  he  died,  he  was 
comatose  ;  there  was  remarkable  hyperpyrexia  ;    the  temperature   rising   on   succeeding 


480  Diseases  of  the  Nervous  System 

days  to  106°  F. ,  108 -6°,  107°,  i07'4°.  and  i07'8°  before  death.  Poj^-wzorz'^w  showed  lymph 
mostly  confined  to  the  interpeduncular  space,  pons,  and  base  of  cerebellum.  Both 
ventricles  contained  fluid  and  lymph  ;  cortex  thinned  to  about  5  inch  in  thickness  from 
internal  pressure. 

A  subacute  basal  meningitis  may  occur  in  older  children,  and  recovery 
from  such  attacks  apparently  takes  place.  Thus  in  a  case  of  our  own — that 
of  a  boy  who  died  suddenly,  in  apparent  health,  and  on  whom  a  coroner's' 
inquest  was  held — an  acute  hydrocephalus  was  present,  with  some  adhesions 
between  the  base  of  the  brain  and  the  skull,  apparently  the  remains  of  a 
meningitis  from  which  there  was  a  history  of  the  boy  having  suffered  some 
months  before. 

As  an  example  of  a  simple  subacute  meningitis  following  an  injury,  the 
following  case  of  Dr.  Button's  may  be  given  : 

Basal  Meningitis,  Hydrocephahis. — William  C. ,  aged  8  years,  fell  into  a  cellar,  striking 
the  back  of  his  head,  some  three  months  before  admission.  He  vomited  off  and  on  for 
a  day  or  two,  but  did  not  lie  up ;  he  suffered  from  pain  in  the  back  of  his  head  almost 
constantly  after  the  fall.  He  was  admitted  with  squint  and  pupils  of  unequal  size ;  he 
had  convulsions,  optic  neuritis,  and  lapsed  into  a  semi-comatose  state  with  Cheyne-Stokes 
respiration.  He  died  twenty-four  days  after  admission.  At  the  post-mortem  the  dura 
mater  was  thickened  and  congested,  there  was  much  lymph  at  the  base  and  between  the 
hemispheres,  and  also  between  the  latter  and  the  cerebellum  ;  the  lateral  ventricles  were 
much  dilated  and  distended  with  serum.     There  were  no  tubercles  anywhere. 

The  following  case  illustrates  the  association  of  subacute  meningitis  and 
hydrocephalus  with  pneumonia  : 

Basal  Meningitis,  Hydrocephalus,  Chronic  Pneumonia. — B.  V.  R.,  aged  5  years,  was 
always  a  healthy  girl  till  seven  weeks  before  admission,  when  she  had  an  attacli  of  feverish- 
ness  and  vomiting ;  she  has  vomited  more  or  less  ever  since  ;  she  has  also  been  losing 
flesh.  On  admission  she  was  drowsy  and  irritable  ;  screaming  when  disturbed  with  a 
shrill  cry  ;  the  head  was  thrown  back,  the  neck  retracted  ;  there  was  no  optic  neuritis.  A 
few  days  after  she  had  two  fits.  She  continued  to  vomit  at  frequent  intervals.  There  was 
much  rigidity  of  the  muscles  of  the  neck,  with  the  head  thrown  back  ;  the  hands  and  arms 
remained  normal,  while  the  hips  and  knees  were  flexed  and  the  abdomen  retracted. 
Later  she  suffered  from  double  pneumonia  at  the  bases,  she  wasted  more  and  more, 
gradually  became  unconscious,  and  died  ten  or  eleven  weeks  from  the  commencement  of 
her  illness.  An  examination  of  the  brain  showed  that  the  Sylvian  fissures  were  matted 
together  with  fibroid  adhesions  ;  similar  adhesions  were  present  in  interpeduncular  space 
and  surrounding  the  third  and  fourth  nerves  ;  fibroid  adhesions  were  also  present  on  the 
upper  surface  of  the  cerebellum.  The  lateral  ventricles  were  much  dilated  and  distended 
with  fluid  ;  there  had  also  been  an  inflammatory  condition  of  their  lining  membrane,  with 
exudation  of  fibrin.  There  was  no  tubercle  anywhere  ;  there  was  a  double  pneumonia 
becoming  caseous. 

It  is  very  probable  that  the  last  three  cases  related  were  not  examples  of 
the  posterior  basal  meningitis  of  infants  just  described- — at  any  rate,  were  not 
caused  by  the  same  micro-organism.  Our  knowledge  is  still  imperfect  re- 
specting the  bacteriology  of  meningitis. 

Epidemic  Cerebro-spinal  Meningitis. — Meningitis  occurs  in  some 
countries  in  epidemics,  and  is  usually  accompanied  by  inflammation  of  the 
membranes  of  the  cord  ;  sporadic  cases,  however,  occur.  Limited  outbreaks 
have  occurred  in  Dublin  and  Glasgow,  but  such  are  rare  in  this  country. 
Both  adults  and  children  are  attacked.     The  symptoms  of  cerebro-spinal 


Epidemic  Cerebj'o-spinal  Meningitis  481 

meningitis  in  infants  closely  resemble  those  of  simple  meningitis,  but 
usually  there  is  more  marked  rigidity  of  the  cervical  muscles  and  muscles  of 
the  spine,  the  legs  may  be  rigid  and  drawn  up,  and  there  may  be  more  or 
less  rigidity  about  the  muscles  of  the  arm  and  forearm.  Sometimes  there 
is  opisthotonos  resembling'  tetanus.  In  older  children  pain  in  the  back  and 
limbs  may  be  complained  of,  being  more  especially  referred  to  the  back  of 
the  neck  or  sacrum  ;  sharp  shooting  pains  may  be  complained  of  in  the 
limbs.  There  may  also  be  general  hyperaesthesia.  In  the  epidemic  foim 
purpura  and  herpetic  eruptions  are  common.  Pneumonia  is  a  common 
complication.  Weichselbaum  has  described  a  diplococcus,  the  D.  intercellu- 
laris  which  he  believes  to  be  the  specific  cause  of  epidemic  cerebro-spinal 
meningitis.  The  diagnosis  between  cerebral  meningitis  and  a  cerebro- 
spinal meningitis  in  infants  is  very  difficult,  often  impossible,  as  it  is  difficult 
to  localise  pain  and  to  arrive  at  a  conclusion  as  regards  a  general  hyper- 
£esthesia.  Retraction  of  the  head  and  more  or  less  rigidity  in  the  limbs  may 
be  present  in  both,  but  they  are  most  marked  when  the  spinal  meninges  are 
affected.  Both  tetanus  and  tetany  may  be  mistaken  for  it ;  in  the  former 
there  is  marked  trismus  before  the  onset  of  the  opisthotonos,  and  the 
temperature  is  normal  or  only  slightly  raised  ;  and  in  the  latter  the  peculiar 
spasm  of  the  muscles  of  the  hands  and  feet,  and  normal  temperature,  suffice 
to  distinguish  the  two  diseases.  Blindness  may  result  from  optic  neuritis, 
and  deafness  from  inflammation  of  the  auditory  nerve.  The  child  may 
recover  its  health  completely,  but  is  blind  and  deaf.  Hydrocephalus  may 
also  take  place.     The  child  may  suffer  from  imbecility. 

Xiatent  Form. — ^Meningitis,  like  peritonitis  and  pleurisy,  may  be  present 
without  giving  rise  to  any  very  definite  cerebral  symptoms  ;  this  is  especially 
so  when  it  occurs  secondarily,  and  the  symptoms  to  which  it  gives  rise  may 
be  overshadowed  by  the  primary  disease.  It  may  occur  in  association  with 
acute  pneumonia  or  peritonitis,  or  acute  intestinal  catarrh,  without  its  pre- 
sence being  suspected,  partly  because  the  headache,  delirium,  and  fever  are 
naturally  attributed  to  the  more  obvious  disease  present,  and  there  is  neces- 
sarily a  difficulty  in  unravelling  the  complex  association  of  symptoms  and 
referring  each  to  its  cause.  In  some  few  instances  a  meningitis  may  exist 
without  there  being  any  cerebral  symptoms  whatever,  as  in  the  following- 
case  : 

Piir/ilent  Meningitis. — An  emaciated  child  (boy)  of  4  years  of  age,  who  had  recently 
suffered  from  whooping  cough,  was  admitted  to  hospital  with  some  dulness  at  the  base  of 
one  lung.  Tliere  was  a  histor}'  of  diarrhoea,  and  during  the  fortnight  preceding  his  death 
he  had  five  or  six  diarrhoeal  stools  dail)'.  There  was  a  hectic  temperature,  no  vomiting, 
headache,  or  optic  neuritis  ;  he  was  perfectly  intelhgent,  and  died  apparently  of  exhaustion. 
It  was  supposed  that  there  was  general  tuberculosis.  At  the  post-mo7-tem  the  lungs  were 
found  adherent  to  the  diaphragm  ;  some  inspissated  pus  was  found  present  at  the  left 
base,  evidentl)'  the  remains  of  a  small  empyema ;  there  were  no  tubercles  anywhere. 
There  was  some  purulent  l)'mph  covering  the  inner  surface  of  the  dura  mater,  the  convex 
surface  of  the  brain,  and  the  vessels  in  the  transverse  fissure,  and  bathing  the  surfaces  of 
the  lateral  ventricles ;  the  base  of  the  brain  was  matted  with  Iraiph.  There  was  clear 
fluid  in  both  tympanic  cavities,  but  no  pus. 

It  is  in  wasted,  anaemic  children  that  such  lesions  as  purulent  men- 
ingitis, pleurisy,  or  peritonitis  may  exist  without  giving  rise  to  marked 
symptoms. 

I  I 


482 


Diseases  of  the  Nervous  System 


Ti-eatmeni. — The  treatment  of  cases  of  non-tuberculous  meningitis  is 
very  much  the  same  as  that  ah^eady  given.  Unfortunately  medicines  can 
do  but  little.  In  the  more  chronic  cases,  blisters  and  iodide  of  potassium  in 
large  doses  are  worth  trying.  Ergot  has  also  been  given.  Morphia,  chloral, 
bromide  may  be  necessary  to  relieve  pain  and  sleeplessness. 


Chronic  ZVIening^o-encephalitis.     Pacliyinening'itis 

Chronic  IVIeningritis. — A  chronic  inflammatory  process,  affecting  iTiOre 
especially  ithe  convex  surface  of  the  brain,  occurs  occasionally  during 
infanc)^,  apparently  also  during  intra-uterine  life.  In  such  cases  the 
surface  of  the  brain  becomes  adherent  to  the  dura  mater,  a  thickening  of 
the  membranes  taking  place  resembling  the  pachymeningitis  of  adults.  A 
membranous  exudation  may  be  thrown  out,  and  blood  may  be  effused.  Carr 
has  recorded  ^  a  case  of  this  sort  in  an  undoubted  syphilitic  child  of  nineteen 
months.  It  had  suffered  from  repeated  convulsions  and  was  idiotic.  At  the 
post-mortem  there  was  no  hydrocephalus,  the  dura  mater  was  lined  by  a 

membrane  of  a  gelatinous  appear- 
ance, the  same  gelatinous  material 
covered  the  cortex  and  base.  The 
brain  weighed  i8  oz.,  there  were 
some  areas  of  sclerosis  bordering 
on  the  fissure  of  Sylvius.  Such  a 
condition  may  be  associated  with 
a  chronic  hydrocephalus.  The 
symptoms  present  are  frequently 
not  distinctive,  or  they  may  be 
simply  those  of  chronic  hydro- 
cephalus ;  there  may  be  defective 
intelligence  or  idiocy,  probably 
also  convulsions  ;  retraction  of  the 
head  and  rigidity  and  flexion  of 
the  limbs  are  likely  to  be  present  if  the  child  lives  any  length  of  time.  The 
etiology  of  such  cases  is  doubtful  :  they  are  always  suggestive  of  hereditary 
syphilis.  As  chronic  hydrocephalus  is  often  associated  with  the  meningitis, 
a  diagnosis  of  hydrocephalus  is  pi'obably  all  that  can  be  made  during  life. 

A  meningitis  during  intra-uterine  life,  by  interfering  with  the  growth  and 
development  of  the  brain,  may  produce  various  results,  such  as  hydrocephalus, 
sclerosis,  or  an  abnormally  small  brain.  Thus  in  a  case^  of  Dr.  T.  Barlow's, 
in  an  infant  dying  at  seven  weeks  of  age,  the  head  measured  only  lo^  inches 
round,  and  the  brain  weighed  only  9  drachms  ;  the  convolutions  were 
hardly  recognisable  over  the  greater  part  of  the  convexity,  and  the  pia 
mater  and  cortex  beneath  it  were  invaded  with  calcareous  plates  ;  the 
choroid  plexuses  of  the  lateral  ventricles  were  also  partially  calcified.  In 
this  case  there  seems  to  have  been  an  intra-uterine  meningitis,  followed  by 
calcification  of  the  effused  lymph  and  some  atrophy  of  the  subjacent  brain 
tissue.       In    the   following   case   there   had   been   apparently   a   meningo- 


Fig.  96. — Microcephalic  infant.  Syphilitic  infant 
four  weeks  old.  (See  case.)  From  a  photograph 
by  Mr.  J.  Hepworth. 


1  Lancet,  January  1895,  p.  154. 


-  Path.  Tra7is.  vol.  xxxviii.  p.  8. 


Chronic  Meninpitis 


483 


encephalitis  occurring  during  fetal  life  giving  rise  to  sclerosis  ;  the  infant 
was  syphilitic. 

The  father  of  the  infant  suffered  from  sore  throat,  rash,  and  serpiginous  ulceration  of 
his  legs.  The  mother,  when  pregnant,  suffered  from  sore  throat,  and  has  had  a  squamous 
syphilide  on  her  face  ;  an  infant  born  subsequently  to  the  patient  suffered  from  coryza  and 
eclampsia.  The  infant  was  first  seen  when  two  weeks  old  :  it  was  microcephalic,  its  head 
measuring  loi  inches  in  circumference  (see  fig.  96),  it  suffered  from  coryza  and  eclampsia. 
It  was  idiotic,  being  unable  to  recognise  anything.  The  fits  continued,  both  arms  and  legs 
became  paretic  and  later  spastic.  It  died  at  five  months  of  age.  The  brain  weighed  3J  oz. 
(after  having  been  in  weak  spirit).  There  was  excess  of  subarachnoid  fluid,  the  arachnoid 
was  milky,  there  was  no  recent  lymph,  but  at  the  base  of  the  brain  there  was  some  yellow 
detritus.     The  convolutions  in  the  Sylvian  fissure  and  neighbourhood  had  mostly  disap- 


Fig.  97. — Brain  of  infant  (fig.  96),  showing  irregular  nodulation  of  surface  from 
meningo-encephalitis.     From  a  photograph  by  Mr.  J.  Hepworth. 


peared,  the  surface  of  the  brain  being  irregular  and  nodular.  There  was  a  depressed  scar- 
ring over  both  frontal  lobes  (see  fig.  97).  There  had  been  a  meningitis  of  the  choroid 
ple.xus  and  hydrocephalus.     No  endarteritis  was  found. 

In  the  following  case,  which  lived  to  be  twenty  months  old,  the  sclerosis 
on  the  surface  of  the  brain  was  well  marked  : 

Fatal  Meningo-encephalitis. — A  child  who  died  at  the  age  of  twenty  months  had  been 
a  complete  idiot  from  his  birth,  and  had  suffered  from  convulsions  ;  he  was  blind  and  deaf  ; 
the  legs  and  arms  were  drawn  up  and  stiff.  At  the  post-mortem  the  brain  was  found  hard 
and  shrunken  over  the  convex  surface  ;  the  convolutions  had  completely  disappeared,  the 
surface  being  simply  grooved  by  the  vessels  and  granular  like  a  '  cirrhosed  '  liver  ;  at  the 
base  and  median  surfaces  the  convolutions  w-ere  fairly  well  marked.  The  pia  mater  con- 
sisted of  many  tortuous  vessels,  which  could  be  dissected  off.  On  vertical  section  it  was 
seen  that  the  grey  matter  and  white  matter  also  were  hard  and  shrunken,  and  hardly 

I  I  2 


484 


Diseases  of  the  Nervous  System 


distinguishable  from  one  another.  Microscopical  examination  showed  an  increase  of  con- 
nective tissue  and  an  absence  of  nerve  elements.  There  was  descending  degeneration  in 
the  pons  and  cord  (see  fig.  98). 

Endarteritis.  Softening-. — An  acute  arteritis  in  rare  instances  occurs  in 
infants  a  few  months  old  who  are  the  subjects  of  congenital  syphilis.  Such 
cases  have  been  recorded  by  Dr.  T.  Barlow,  Chiari,  and  Heubner. 

In  infants,  the  principal  symptoms  are  convulsions,  in  the  form  of 
muscular  twitchings  of  an  arm  or  leg,  followed  by  paresis  and  contractures. 
The  infant  gradually  becomes  idiotic.  The  chief  changes  are  in  the  arteries 
as  described  by  Heubner  :  there  is  a  thickening  of  the  internal  coat,  the 
nuclei  between  the  endothelium  and  the  fenestrated  membrane  becoming 


r 


Fig.  98. — Sclerosis  of  Brain.  From  a  boy  of  twenty  months.  The  convolutions  have  dis- 
appeared, the  surface  of  the  brain  resembling  a  hob-nail  liver  (probably  syphilitic).  The 
openings  which  transmitted  the  meningo-cephalic  vessels  appear  as  black  points. 


increased  in  number,  to  be  followed  by  fatty  changes  ;  thrombosis  takes 
place  at  the  seat  of  the  inflammatory  changes.  Softening  of  the  brain 
follows  over  the  area  supplied  by  the  blocked  arteries.  The  following  case 
illustrates  this  : 

Syphilitic  Arteritis.  Softening. — Infant  first  seen  at  three  months  of  age,  when  suffer- 
ing from  coryza  and  a  well-marked  rash.  A  month  later  the  epiphyses  of  the  lower  end 
of  the  tibia  and  fibula,  also  the  lower  ends  of  the  radius  and  ulna,  were  swollen  and  tender 
(fig.  93  was  drawn  from  this  case).  When  seven  months  old  he  began  to  suffer  from  con- 
vulsions, mostly  left-sided  at  first,  later  the  convulsive  movements  became  general.  In  the 
course  of  a  few  months  the  left  arm  and  leg,  which  were  more  or  less  paralysed,  began  to 
draw  up  and  become  more  or  less  rigid  ;  the  elbow  was  bent  at  right  angles,  the  arm  pro- 
nated,  and  the  fingers  flexed  ;  still  later  the  right  arm  became  similarly  affected  ;  the  child 
gradually  became  idiotic,  and  died  at  four  months  old.  It  was  under  mercurial  treatment 
from  three  months  of  age.  At  the  post-mortem  the  arachnoid  was  of  a  milky  colour,  and 
there  was  an  excess  of  subarachnoid  fluid  ;  there  was  no  effused  lymph  or  meningitis. 
The  superficial  layer  of  the  grey  matter  on  the  convex  surface  of  both  hemispheres, 
especially  the  right,  was  softened  and  could  be  readily  scraped  away ;  the  superficial 
layer  of  the  caudate  nucleus  and  optic  thalamus  were  in  the  same  condition  of  softening. 
Microscopically,  the  grey  matter  showed  extensive  fatty  degeneration  ;  the  minute  arteries 
were  extensively  blocked  with  old  thrombi,  their  inner  coats  being  thickened  and  their 


Pachyinenuigitis — Acute  Hydrocephalus  485 

nuclei  incrt'asL'cl  in  number.  The  large  arteries  were  normal,  as  far  as  could  be  made  out. 
There  seems  to  have  been  an  extensive  syphilitic  arteritis  of  the  small  meningo-encephalic 
arteries,  thrombosis,  and  secondary  softening  of  the  superficial  grey  matter. 

Pacbymening'itis,  with  thickening  of  the  dura  mater  and  adhesions 
to  the  brain  and  skull,  with  wasted  convolutions  of  the  brain  and  endarteritis, 
are  found  in  cases  of  syphilitic  dementia  (see  p.  454).  The  paresis  and 
dementia  commence  shortly  before  puberty  ;  there  is  usually  more  or  less 
blindness  from  disseminated  choroiditis  and  deafness.  The  course  is  very 
chronic. 

Rydrocepbalus 

Acute  Hydrocepbalus  occurs  only  in  association  with  an  acute  men- 
ingitis. In  the  majority  of  cases  of  acute  meningitis,  whether  tuberculous  or 
simple,  there  is  an  excess  of  fluid  in  the  lateral  ventricles,  the  result  of  an 
intra-ventricular  meningitis,  and  a  consequent  excessive  exudation  from  the 
vessels  of  the  choroid  plexus.  In  exceptional  cases  the  meningitis  is  con- 
fined to  the  ventricles.  In  those  rare  cases  where  an  acute  or  subacute 
meningitis  ends  in  recovery  a  chronic  hydrocephalus  may  be  left ;  in  these 
cases  the  head  slowly  enlarges  in  succession  to  the  symptoms  of  a  meningitis. 
Excess  of  fluid  may  be  found  in  the  subarachnoid  space  in  acute  meningitis. 

Cbronic  Hydrocepbalus. — The  accumulation  of  an  excess  of  fluid  in 
the  ventricles  of  the  brain  is  by  no  means  an  uncommon  condition  in  infants 
and  children .  ( i )  1 1  may  be  congenital,  th e  accumulation  taking  place  before 
birth,  and  it  may  give  rise  to  difficulty  in  the  extraction  of  the  head.  (2;  It 
may  follow  an  acute  meningitis  or  subacute  meningitis.  (3)  It  may  arise 
without  any  apparent  cause.  (4)  It  may  be  the  result  of  a  tumour,  as  for 
instance  a  tumour  of  the  cerebellum,  compressing  the  veins  of  Galen,  and  in 
other  ways  interfering  with  the  circulation. 

In  the  majority  of  cases  the  child  is  born  healthy,  and  the  enlargement 
of  the  head  is  first  noticed  when  the  infant  is  a  few  weeks  to  a  few  months 
old ;  usually  no  cause  can  be  assigned,  but  some  of  the  cases  are  syphilitic, 
and  it  is  not  improbable  that  syphilis  plays  an  important  part  in  the  pro- 
duction o'f  hydrocephalus.  Enlargement  of  the  head  is  preceded  in  a  few 
cases  by  distinct  cerebral  symptoms,  as  convulsions,  fever,  drowsiness,  and 
retraction  of  the  head,  so  as  to  suggest  the  probability  of  the  meningitis 
perhaps  being  local  rather  than  general.  As  the  fluid  accumulates  in 
the  ventricles  the  head  enlarges,  the  bones  forming  the  vault  of  the  cranium 
become  thinned  and  open  out,  so  that  the  fontanelles  are  enlarged  and  the 
edges  of  the  bones  at  the  sutures  are  separated  from  one  another  (see  fig.  99). 
The  fontanelles  are  bulged  and  have  a  fluctuating  feel,  the  occipital  and 
parietal  bones  may  be  so  thin  that  moderate  pressure  with  the  finger  is  suffi- 
cient to  bulge  them  in.  The  cranium  assumes  a  spherical  form,  and  its 
increased  size  contrasts  with  the  child's  face,  which  may  be  thin  and  sunken, 
giving  the  child  a  characteristic  appearance.  The  forehead  is  rounded, 
and  projects  so  as  to  overhang  the  face  ;  the  parietal  and  occipital  bones 
assume  a  similar  shape,  so  that  the  head  has  a  globular  or  rounded  form. 
There  may  be  nystagmus.  The  general  rounded  contour  is  broken  by  the 
prominence  of  the  frontal  and  parietal  eminences  ;  at  these  spots  the  bone 


486 


Diseases  of  the  Nervous  System 


is  thick  and  solid,  and  consequently  cannot  be  bulged  out  like  the  thinner 
bone  elsewhere.  The  skin  of  the  forehead  and  scalp  is  thin  and  shiny  from 
being  stretched,  and  the  cutaneous  veins  are  distended,  especially  when  the 
infant  cries  ;  the  eyes  project  :  their  axes  may  be  divergent,  and  there  may 
be  difficulty  in  closing  the  eyelids.  The  infant  cannot  raise  its  head,  and  if 
propped  up  the  head  rolls  over  in  a  helpless  sort  of  way.  The  condition  of 
the  intellect  varies  considerably  \  in  the  majority  of  cases,  where  the  hydro- 
cephalus is  moderate  in  degree,  the  intellectual  powers  are  suriDrisingly  good 
when  it  is  considered  what  amount  of  compression  and  flattening  out  the 
grey  matter  on  the  surface  of  the  brain  is  exposed  to  by  the  accumulation  of 


Fis 


gg. — Outline  of  Head  in  Chronic  Hydrocephalus. 
a  a,  frontal  bones  ;  bb,  parietal  bones. 


fluid  in  the  lateral  ventricles.  In  extreme  cases  there  is  certain  to  be  marked 
intellectual  defect,  perhaps  amounting  to  idiocy.  The  limbs  are  mostly 
paretic,  and  the  lower  extremities  especially  are  rigid,  and  flexed  upon  the 
abdomen  ;  permanent  contractures  are  apt  to  follow,  a  result  probably  due 
to  compression  of  the  pons.  Atrophy  of  the  optic  nerves  may  take  place 
from  compression  or  stretching  of  the  optic  tracts  or  commissure.  The 
course  of  the  disease  is  usually  chronic,  and  infants  will  live  for  months  or 
even  years,  but  ordinarily  they  gradually  waste  and  die.  The  child  shown 
in  fig.  I  GO,  who  was  6i^  years  of  age,  had  suffered  from  chronic  hydrocephalus 
since  three  months  old  ;  he  was  well  nourished  ;  his  head  measured 
31. V  inches  in  circumference  ;  he  was  a  complete  idiot.     The  legs  were  bent 


CJi  ron ic  Hj 'droccph alus 


487 


at  the  knee  and  flexed  on  the  abdomen,  but  the  spasm  of  the  muscles  varied 
from  time  to  time  ;  the  hands  were  kept  closed,  and  the  elbows  were  flexed 
and  more  or  less  rigid.  We  have  known  recovery  to  take  place,  even  after 
rigidity  of  the  legs  has  come  on. 

In  older  children,  when  the  disease  comes  on  after  the  closure  of  the  fon- 
tanelles,  the  head  enlarges  more  gradually,  thinning  the  bones  and  even  open- 
ing up  the  fontanelles  and  sutures  ;  in  these  cases  the  hydrocephalus  is  mostly 
due  to  a  cerebellar  tumour  ;  blindness  and  imbecility  gradually  supervene. 

Diag7iosis. — This  is  not  ditificult  when  the  disease  is  well  advanced  ; 
difficulty,  however,  occurs  in  the  early  stages  when  the  accumulation  of  fluid 
is  small,  and  when  hydrocephalus  may  be  mistaken  for  a  rickety  skull,  or 
simply  a  large  head  without  distension  of  the  lateral  ventricles  such  as  occurs 
in  rickets.  The  friends  of  patients  often  ask  whether  a  child  who  has  a  large 
head  has  '  water  on  the  brain.'  A 
diagnosis  can  only  be  made  when 
the  head  enlarges  under  observa- 
tion, the  bones  becoming  thinned, 
the  fontanelles  bulged  and  fluctu- 
ating ;  the  globular  shape  which 
it  assumes  distinguishes  it  from 
the  misshapen  head  of  a  typical 
case  of  rickets  with  the  prominent 
eminences,  flattened  vertex,  and 
thick  edges  of  the  bones.  In  the 
simply  enlarged  head,  from  the 
presence  of  an  abnormally  enlai^ged 
brain,  there  is  no  opening  out  and 
bulging  at  the  fontanelles,  nor 
usually  any  evidence  of  a  thin 
skull. 

Morbid  Ajiato7ny. — In  those 
cases  in  which  the  excessive  quan- 
tity of  fluid  in  the  ventricles  is 
caused  by  a  cerebellar  tumour 
the  mechanism  is  tolerably  clear, 

for  any  stretching  of  the  tentorium  cerebelli  must  compress  the  straight 
sinus  which  runs  along  at  the  base  of  the  falx  cerebri,  and  consequently 
check  the  onward  flow  of  blood  in  the  veins  of  Galen  and  inferior  longitudinal 
sinus.  As  the  veins  of  Galen  return  the  blood  of  the  choroid  plexus,  it  is 
easy  to  understand  how  a  chronic  hydrocephalus  may  be  thus  produced. 
In  these  cases  the  lateral  ventricles  are  distended  with  a  clear  fluid  of  low 
specific  gravity,  the  third  and  fourth  ventricles  join  in  the  dilatation,  and  the 
iter  is  also  enlarged.  In  another  class  of  case  which  occurs  after  a  basal 
meningitis  (seep.  479),  it  is  clear  that  the  adhesions  which  form  in  the  neigh- 
bourhood of  the  fourth  ventricle  have  the  effect  of  sealing  up  the  communica- 
tion between  the  lateral  ventricles  and  the  subdural  space  by  closing  the 
aqueduct  of  Sylvius  and  transverse  fissure.  There  is  no  escape  for  the  fluid 
secreted  in  the  lateral  ventricles,  and  it  is  consec^uently  ponded  up  and 
gradually  distends  the  ventricles  as  it  increases.     In  those  cases  which  form 


Fia 


100. — Chronic  Hydrocephalus  in  a  boj'  aged 
6|  years. 


488  Diseases  of  the  Nervous  System 

the  majority,  where  no  tumour  is  present,  and  no  evidence  of  a  past  or  present 
meningitis,  the  mechanism  of  the  hydrocephalus  is  by  no  means  clear.  In 
these  cases  the  lateral  ventricles  and  their  horns  may  be  enormously  dilated, 
the  grey  matter  on  the  surface  is  flattened  out  and  reduced  in  some  cases  to 
the  thickness  of  cardboard,  the  convolutions  being  lost  or  only  traced  with 
difficulty.  The  contained  fluid  is  clear,  of  specific  gravity  about  1005,  with 
a  small  quantity  of  albumen  and  salts  ;  the  third  and  fourth  ventricles  are 
dilated  ;  the  pons  is  often  flattened  by  the  pressure  of  fluid  in  the  fourth 
ventricle.  In  these  cases,  where  there  is  no  apparent  obstacle  to  the  escape 
of  the  fluid  from  the  ventricles,  no  satisfactory  explanation  of  the  hydro- 
cephalus is  forthcoming.  In  some  cases  at  least  there  may  be  some  inflam- 
matory condition  of  the  choroid  plexuses,  but  as  a  rule  the  lining  membrane  of 
the  ventricles  and  choroid  plexuses  are  healthy  to  the  naked  eye.  It  would 
appear  that  for  some  unknown  reason  there  is  an  excessive  secretion  of 
cerebro-spinal  fluid. 

Treatment. — The  treatment  of  chronic  hydrocephalus  when  once  esta- 
blished is  unfortunately  unsatisfactory,  and  but  little  can  be  done  to  influence 
the  progress  of  the  disease.  In  any  case  in  which  there  is  reason  to  suspect 
syphilis  some  mercury  should  be  given  internally,  and  some  ung.  hydrarg. 
applied  to  the  head  ;  or  strips  of  mercury  plaister  may  be  used  to  effect  a 
moderate  compression  and  aid  the  absorption  of  the  drug.  Some  cases  in 
infants  appear  to  be  benefited  by  this  treatment  ;  but,  presuming  there  is  a 
chronic  syphilitic  meningitis,  it  is  by  no  means  certain  to  be  influenced 
by  anti-syphilitic  treatment.  Both  mercury  and  iodides  should  be  tried, 
especially  as  there  is  no  other  drug  which  affords  any  chance^  of  success. 
Some  success  has  been  claimed  for  compression  of  the  head  by  means  of 
strips  of  plaister  or  an  elastic  bandage  ;  if  it  is  decided  to  try  this  method 
its  risks  must  be  borne  in  mind.  The  circulation  through  the  scalp  is 
interfered  with  by  its  compression  between  the  skull  and  bandage,  the 
brain  is  also  compressed  between  the  skull  and  the  fluid  in  the  ventricles. 
We  have  seen  extensive  sloughing  of  the  scalp  in  a  case  of  hydrocephalus, 
the  result  of  a  too  tightly  applied  elastic  bandage.  No  real  compression  can 
be  of  any  service,  and  is  decidedly  risky  ;  but  a  lightly  applied  bandage  may 
be  of  use  as  a  support.  Puncture  with  one  of  Southey's  cannulas  through 
the  anterior  fontanelle,  avoiding  the  superior  longitudinal  sinus,  offers  more 
chance  of  at  least  temporary  relief.  It  is  usually  harmless,  though  if  too 
much  be  withdrawn  there  is  a  risk  of  collapse  of  the  brain  substance,  with 
perhaps  convulsions  and  sudden  death.  We  have  frequently  drawn  off  as 
much  as  12  oz.  through  one  of  Southey's  cannute,  but  the  fluid  reaccumulates 
.in  a  few  days.  In  some  recorded  cases  a  rapid  rise  of  temperature  and 
sudden  death  took  place  when  the  lateral  ventricles  were  quickly  emptied 
(Sutherland). 

Of  other  methods  of  treatment  we  have  had  no  experience.  Pott  has 
treated  chronic  hydrocephalus  by  incision  and  drainage,  and  Ranke  by 
puncture  and  injection  of  tincture  of  iodine  (10  grms.  diluted  with  2ogrms.  of 
water).  It  cannot  be  said  with  much  success.  More  recently  Sutherland 
and  Watson  Cheyne  have  devised  a  method  of  draining  the  over-distended 
lateral  ventricles  into  the  subdural  space  by  means  of  a  bundle  of  fine  catgut. 
The  catgut  drain  is  so  arranged  that  one  end  projects  into  the  ventricle,  the 


Hypertrophy  and  Atrophy  of  the  Brain  /I.89 

other  end  into  the  subdural  space.  The  wound  in  the  dura  mater  and  skin 
necessary  to  insert  the  drain  is  then  sutured  up.  In  the  cases  operated  on 
the  fluid  gradually  diminished  as  the  ventricle  drained,  but.  in  one  case  a 
second  operation  was  necessary  to  drain  the  other  ventricle.  It  is  possible 
that  this  operation  may  be  of  "use  in  cases  of  chronic  hydrocephalus  follow- 
ing basal  meningitis.' 

Hypertrophy  of  the  Brain. — Rickety  children  often  have  abnormally 
large  heads,  a  condition  which  is  frec^uently  attributed  to  '  water  on  the 
brain.'  In  reality  such  abnormally  large  heads  are  not  hydrocephalic, 
their  increased  size  being  due  in  some  cases  to  the  prominent  frontal  and 
parietal  eminences,  but  more  often  to  an  enlarged  brain.  The  cause  of  this 
hypertrophy  is  not  known,  and  the  nature  of  the  enlargement  in  the  brain, 
liver,  or  spleen,  which  is  apt  to  take  place  in  rickets,  is  not  clearly  under- 
stood. In  several  cases  coming  under  notice  of  children  in  their  second  and 
third  years,  with  large  heads,  who  have  had  rickets  in  a  severe  form  and  who 
have  died  in  convulsions,  the  brains  have  been  large,  the  convolutions  well 
marked,  the  brain  substance  fairly  firm,  and  the  microscopical  examinations 
revealed  no  change  that  we  could  detect.  Such  brains  are  usually  very  vas- 
cular, but,  as  death  often  takes  place  through  convulsions,  it  is  hardly  safe  to 
assert  that  the  vascularity  is  anything  more  than  a  secondary  effect,  result- 
ing from  the  manner  of  death.  In  some  cases  the  increase  in  size  has  been 
attributed  to  an  increase  of  the  connecting  elements,  the  neuroglia,  but  it  is 
needless  to  say  it  is  a  very  difficult  matter  to  decide  if  this  is  so  in  a  brain 
in  which  the  enlargement  is  general  ;  in  our  own  cases,  certainly,  there  was 
no  striking  change.  It  is  certain  that  enlargement  of  the  brain  in  these 
cases  is  not  accompanied  by  any  precocity  of  intellect  ;  indeed,  it  is  rather  the 
reverse,  as  such  children  are  mostly  backward,  not  only  in  physical,  but  also 
in  mental  development.  If  the  c[uantity  of  brain  matter  is  large,  the  quality 
is  certainly  poor. 

Atrophy  of  the  Brain. — The  brain  may  be  of  abnormally  small  size, 
and  yet  the  brain  substance  normal  ;  in  such  cases  there  is  usually  more  or 
less  mental  defect. 

In  some  cases  of  children  who  have  suffered  from  chronic  wasting 
secondary  to  gastro-intestinal  atrophy,  during  the  last  few  weeks  of  life  the 
lower  limbs  become  more  or  less  flexed  and  rigid  and  the  abdomen  some- 
what retracted.  At  the  post-mortem  the  cerebral  hemispheres  are  partially 
shrunken  and  an  excessive  quantity  of  fluid  is  present  in  the  subdural  and 
subarachnoid  spaces.  Presumably  this  atrophy  is  secondary  to  malnutrition 
the  result  of  failure  of  the  digestive  powers. 

In  the  following  curious  case,  atrophy  or  shrinking  of  one  half  of  the  Ijrain 
appeared  to  follow  a  fall  on  the  head  : 

Atrophy  of  a  Cerebral  Hemisphere. — Bernard  H.,  sixteen  months,  admitted  to  the 
Children's  Hospital,  April  1893.  The  mother  states  the  boy  was  perfectly  healthy,  and  had 
the  use  of  his  limbs  up  to  fourteen  weeks  ago,  when  he  accidentally  fell  off  a  table,  striking 
the  left  side  of  his  forehead  on  the  floor.      He  was  picked  up  unconscious,  and  remained 


1  For  details  of  the  operation  see  Brit.  Med.  Journal,  Oct.  15,  1898  ;  and  Clinical  Sac. 
Trans,  vol.  xxxi. 


490 


Diseases  of  the  Nervous  System 


so  for  three  hours  ;  on  consciousness  returning  he  was  convulsed.  The  next  day  he  was 
again  convulsed  and  again  became  unconscious,  in  which  condition  he  remained  for  three 
weeks.  At  the  end  of  this  time  he  regained  consciousness,  and  it  was  found  that  his 
right  side  was  paralysed.  On  admission  he  was  a  well-nourished  child,  his  skull  was  well 
shaped  and  symmetrical,  his  right  arm  and  leg  were  in  a  condition  of  spastic  paralj'sis, 
resisting  any  attempt  to  extend  them  ;  there  was  no  squint,  but  slight  nystagmus.  He 
was  very  fretful  and  not  intelligent.  As  it  was  supposed  there  was  a  clot  of  blood  com- 
pressing the  left  hemisphere  it  was  decided  to  explore.  On  trephining  the  dura  was 
purplish  in  colour  and  partially  calcified  on  dividing  it  ;  much  clear  fluid  escaped  ;  there 
was  evidently  an  enlarged  subdural  space.  The  child  sank  twenty-four  hours  after  the 
operation.     At  \\\t  post-mortem  it  was  noted  both  sides  of  the  skull  were  symmetrical,  the 


Fig.  loi. — Showing  Atrophy  of  left  side  of  the  Cerebrum.     The  right  lobe 
the  cerebellum  is  slightly  smaller  than  the  left. 


left  hemisphere  was  much  smaller  than  the  right  (see  figs.  loi  and  102),  the  right  side  o. 
the  cerebellum  slightly  smaller  than  the  left.  There  was  no  trace  of  a  past  meningitis 
or  haemorrhage,  and  no  thrombosis  or  embolism.  The  convolutions  on  the  left  hemisphere 
were  wasted,  but  not  markedly  so,  the  pia  mater  peeled  off  readily  ;  vertical  sections,  after 
hardening  in  Miiller's  fluid,  showed  there  had  been  a  general  shrinking  of  the  left  hemi- 
sphere, or,  at  any  rate,  all  parts  were  proportionately  smaller  than  the  right ;  there  was 
some  hypertroph}'  of  the  right  side.  Microscopical  examination  showed  there  had  been  a 
chronic  inflammatory  induration  of  the  left  hemisphere.  It  was  suggested  that  the  case  was 
really  congenital,  the  history  being  misleading  ;  against  this  view,  however,  is  the  fact  that 
the  skull  was  symmetrical  and  was  no  smaller  on  the  left  side  than  the  right ;  and  the 
mother  was  very  positive  with  regard  to  his  being  quite  well  up  to  the  time  of  the  accident. 
He  had  not  suffered  from  convulsions  previously  to  the  fall. 


Tumours  of  tJtc  Brain 


491 


Tumours   of  the  Brain 

While  cerebral  tumours  arc  by  no  means  uncommon  during  childhood, 
the  ditterent  varieties  found  are  few.  In  the  vast  majority  of  cases  the  tumour 
or  tumours  consist  of  caseous  masses  formed  by  a  local  tubercular  process. 
These  tubercular  masses  especially  have  a  marked  predilection  for  the 
cerebellum,  but  are  found  also  comparatively  frecjuently  in  the  pons,  basal 
ganglia,  and  cerebral  hemispheres,  both  on  the  surface  and  in  the  connecting 
white  substance.  Cysts  of  uncertain  origin  are  also  found,  especially  in  the 
cerebellum.  The  pons  seems  the  favourite  seat  of  gliomas  when  they  occur. 
Other  new  growths,  such  as  epithelial  carcinomata,  may  be  occasionally 
found  growing  from  the  choroid  plexus  or  pia  mater.  Periosteal  sai'comata 
growing  from  the  bone  are  not  uncommon,  compressing  the  grey  matter. 
No  age  is  exempt  ;  tubercular  tumours  have  been  found  in  infants  a  few 
months  old,  though  they  are  more  common  somewhat  later.  Demme  found 
a  cheesy  mass  in  the  cerebellum  of  a  newly  born  child,  so  that  tumours  may 


B 


;  L 


102.— Transverse  Section  of  Brain  shown  in  fig.  loi.     The  space  between  the  left  side 
of  the  cerebrum  and  the  dura  mater,  shown  by  dotted  line,  contained  fluid. 


form  during  intra-uterine  life.  Little  is  known  as  to  the  cause  which  de- 
termines the  growth  in  the  brain  or  its  coverings  ;  it  appears  certain,  how- 
ever, that  an  injury  acts  as  an  exciting  cause.  A  fall  or  blow  on  the  head  is 
followed  in  the  course  of  a  few  weeks  or  months  by  cerebral  symptoms.  On 
the  fatal  termination  a  cheesy  tumour  is  found  in  the  cerebellum.  How  the 
injury  can  have  given  rise  to  this  can  only  be  surmised  ;  possibly  there  is  a 
local  bruising  and  punctiform  haemorrhage.  The  most  common  tumour  to 
follow  a  blow  is  a  tubercular  tumour,  but  then  tubercular  tumours  are  vastly 
more  common  than  any  others  ;  nevertheless  a  cyst  or  a  syphiloma  or  a 
periosteal  sarcoma  does  appear  to  follow  a  blow  at  times. 

Symptoms. — The  general  symptoms  include  :  (i)  persistent  headache  ; 
(2)  paroxysmal  vomiting  ;  (3)  optic  neuritis  ;  (4)  convulsions.  The  local  syxi\- 
ptoms  are  those  caused  by  the  tumour  interfering  with  the  function  of  some 
region,  and  causing  some  local  paralysis  or  spasm,  or  incoordination  of  move- 
ments, or  pressure  on  some  venous  channel  and  consequent  disturbance  of 
the  circulation. 

Headache  is  almost  constantly  present,  though  in  young  children,  who  are 
unable  to  complain  or  describe  their  feelings,  its  presence  or  absence  cannot 


492  Diseases  of  the  Nervous  System 

be  determined.  Its  locality  may  help  to  indicate  the  seat  of  the  lesion, 
but  for  this  purpose  it  is  an  uncertain  guide  ;  it  may  be  either  frontal  or 
occipital  in  tumours  of  the  cerebellum,  and  it  may  shift  about  from  time  to 
time,  but  if  fixed  and  constant  at  one  spot  it  is  of  some  value  for  localisation. 
It  is  usually  tolerably  constant,  or  not  absent  for  long  together,  but  is  apt  to 
be  much  worse  at  some  times  than  others.  It  is  mostly  made  worse  by  move- 
ment, and  when  the  child  is  up  and  about,  and  is  better  when  it  is  at  rest  and 
lying  down.  Percussion  over  the  seat  of  the  headache  usually  makes  it 
worse  or  gives  acute  pain,  but  it  is  seldom  of  any  diagnostic  value  in 
children.  The  headaches  most  likely  to  be  mistaken  for  those  due  to  a  tumour 
are  the  hysteroid  headaches,  which  are  often  very  persistent  and  severe. 

Vomiting  is  a  frequent  and  very  characteristic  symptom,  and  may  be  present 
in  tumours  of  all  parts  of  the  brain,  especially  of  the  cerebellum,  pons,  and 
medulla,  and  when  the  root  of  the  pneumo-gastric  is  involved.  The  vomiting 
usually  comes  on  suddenly  without  warning,  and  without  much  nausea,  and 
may  be  repeated  daily  or  several  times  a  week  without  any  cause  being  de- 
tected :  such  vomiting  is  very  suggestive  of  cerebral  disease,  though  it  must 
not  be  forgotten  that  hysterical  vomiting  also  occurs,  especially  in  girls  about 
puberty.  There  may  be  nausea  and  constant  sickness,  with  much  retching,  ■ 
in  the  later  stages  of  a  cerebral  tumour.  It  is  often  paroxysmal,  coming  on 
and  lasting  for  several  days  continuously,  being  not  amenable  to  treatment, 
and  then  suddenly  improving. 

Optic  7teuritis  occurs  in  the  majority  of  cases  sooner  or  later,  and  is 
especially  common  in  tumours  of  the  cerebellum,  less  so  in  those  of  the  frontal 
regions.  The  discs  become  swollen,  so  that  on  examination  the  edges  appear 
at  first  blurred,  and  then  all  distinction  between  the  edges  of  the  disc  and 
retina  is  lost,  even  to  the  direct  method  of  examination.  The  veins  become 
distended  and  tortuous,  and  heernorrhages  occur  ;  finally,  after  some  months, 
the  discs  gradually  pass  into  a  condition  of  atrophy.  The  exact  cause  of 
optic  neuritis  is  uncertain  ;  it  occurs  in  association  with  tumours  in  all  parts 
of  the  brain,  but  may  be  absent  from  first  to  last ;  it  has  been  known  to  occur 
in  otitis  and  in  disease  of  the  cord  without  any  discoverable  cerebral  lesion. 
In  a  case  of  our  own  of  acute  otitis,  there  was  optic  neuritis,  and  no  lesion  of 
the  brain  was  discovered  ^cj-/  morteyn.  The  neuritis  appears  to  be  in  some 
cases  a  descending  one,  passing  along  the  sheath  of  the  optic  tract  and  pro- 
ducing an  intense  inflammation  at  the  papilla  ;  but  this  can  hardly  be  the 
case  often  :  it  is  much  more  likely  to  be  a  reflex  inflammation,  such  as  herpes 
facialis,  which  so'  often  appears  on  the  lips  and  face  in  inflammatory  con- 
ditions of  the  respiratory  tract.  Optic  neuritis,  it  is  important  to  remember, 
may  occur  without  any  loss  of  sight,  though  as  atrophy  sets  in  the  sight  is 
certain  to  be  damaged.  It  is  often  of  great  diagnostic  importance,  its  presence 
being  of  much  value  as  an  indication  of  a  cerebral  lesion,  though  its  absence 
in  any  given  case  where  other  symptoms  point  to  some  cerebral  lesion  does 
not  necessarily  negative  the  diagnosis.  Optic  neuritis  may  come  on  either 
early  or  late  in  the  disease. 

Giddiness  is  often  complained  of,  most  commonly  in  disease  of  the  cere- 
bellum and  pons. 

Co7ivulsions. — The  first  symptom  may  be  a  convulsion,  which  may  never 
be  repeated,  or  convulsions  maybe  frequent  during  the  course  of  the  disease. 


Tuiuoius  of  the  Cerebellum  493 

and  may  occur  in  tlie  case  of  tumours  of  any  part,  but  more  especially  when 
the  growth  involves  or  compresses  the  motor  cortical  centres  than  when  the 
cerebellum  is  involved.  Such  convulsions  may  be  epileptiform,  but  without 
aura.  In  these  cases  the  nature  of  the  aura  and  the  commencement  of  the 
fits  in  some  special  part  afford  an  indication  of  the  seat  of  the  tumour  which 
is  situated  in  the  cortex.  The  convulsions,  which  commence  in  one  part, 
may  cjuickly  become  general. 

Paralysis. — ^The  various  paralyses  and  other  local  symptoms  will  be 
referred  to  later  on  under  the  regional  symptoms. 

Tumours  of  the  Cerebellum. — One  of  the  common  seats  for  a  cheesy 
mass  is  in  the  lateral  lobes  of  the  cerebellum.  It  is  not  uncommon  to  find 
these  masses  varying  in  size  from  a  pea  upwards  in  the  lateral  lobes  of  a 
child  who  has  died  of  tubercular  meningitis,  without  any  definite  signs  of 
their  presence  having  been  given  during  life.  In  cases  of  cerebellar  tumour 
which  have  pro\'ed  fatal,  a  cheesy  mass  may  be  found  which  has,  perhaps, 
become  adherent  to  the  posterior  fossa  of  the  skull  and  tentorium,  and  has, 
very  likely,  extended  across  the  middle  line,  encroaching  on  the  medulla, 
and  so  compressed  the  motor  tracts  passing  downward  to  the  cord.  Another 
pressure  effect  is  the  compression  of  the  straight  sinus  by  the  stretching  of 
the  tentorium  and  a  consequent  pounding  up  of  the  blood  in  the  venae  Galeni, 
and  chronic  effusion  of  fluid  in  the  lateral  ventricles.  A  large  cerebellar 
tumour  is  almost  certain  to  be  accompanied  by  chronic  hydrocephalus,  the 
lateral  ventricles  are  greatly  dilated,  the  skull  thinned,  and  perhaps  the  pons 
may  be  more  or  less  compressed  and  flattened  by  the  pressure  of  the  fluid. 
A  tumour  of  the  middle  lobe  is  more  likely  to  compress  the  motor  tracts  in 
the  floor  of  the  fourth  ventricle  than  one  in  the  lateral  lobes.  A  simple  cyst 
in  the  cerebellum  is  not  uncommon. 

Symptoms.- — ^The  history  obtained  from  the  friends  usually  includes 
headache,  more  or  less  vomiting,  and  scjuint.  In  young  children  it  may 
be  that  enlargement  of  the  head  and  more  or  less  blindness  are  early 
noticed. 

An  examination  of  the  patient  elicits  the  fact  that  the  headache  is  either 
frontal  or  occipital,  and  of  varying  intensity  ;  in  one  of  our  cases  the  pain 
was  always  referred  to  the  right  occipital  region,  and  the  boy  would  sometimes 
be  found  asleep  with  his  hand  placed  on  this  spot.  At  the  post-mortem 
examination  a  large  sarcomatous  tumour  was  found  in  the  right  lobe  of  the 
cerebellum.  It  is,  however,  not  common  for  the  patient  to  be  able  to 
localise  the  lesion  in  this  way.  The  headache  is  usually  described  as  an 
'ache'  rather  than  as  a  sharp  pain,  but  in  some  cases  we  have  known  it  to 
be  intense,  suggesting  the  presence  of  meningitis.  The  vomiting,  like 
cerebral  vomiting  generally,  is  fitful  and  uncertain  ;  as  a  rule  it  is  not  per- 
sistent, and  it  comes  and  goes  in  an  eiTatic  manner.  It  is  rarely  troublesome 
when  the  patient  is  at  rest  in  bed.  Internal  squint  is  in  our  experience  an 
early  and  frequent  symptom  ;  it  is  not  always  double,  and  sometimes  one 
eye  is  affected  more  than  the  other  ;  the  strabismus  is  due  to  a  paresis  of  the 
sixth  nerves,  and  not  to  a  spastic  condition  of  the  internal  recti.  In  one  case 
coming"  under  our  notice  a  boy  who  suffered  from  headache,  and  who  had 
developed  an  internal  squint,  was  operated  on  for  the  strabismus  by  a 
surgeon  ;  the  latter,  however,  altered  his  opinion  with  regard  to  the  case 


494  Diseases  of  the  Nervotcs  System 

when  he  discovered  optic  neuritis  to  be  present.  The  boy  had  a  cerebellar 
tumour.  Optic  neuritis  is  a  common  and  early  symptom  ;  greater  or  less 
limitation  of  the  field  of  vision  and  blindness  usually  follow. 

In  all  cases  there  is  sooner  or  later  a  peculiar  gait  or  walk,  due  to  more 
or  less  weakness  in  the  legs.  This  peculiar  gait  is  often  described  as 
'ataxic,'  and  '  cerebellar  ataxia'  is  sometimes  said  to  be  present  ;  or  there  is 
a  staggering  gait,  or  a  difficulty  in  maintaining  the  equilibrium.  Sometimes 
attention  is  called  to  a  patient's  supposed  tendency  to  fall  forward  or  back- 
ward, or  to  one  side.  Now  it  is  certainly  true  that  the  patient's  friends  often 
give  a  history  of  staggering  or  easily  falling",  and  if  a  child  with  a  cerebellar 
tumour  is  got  out  of  bed  and  made  to  promenade  up  and  down  the  ward,  he 
will  most  likely  sway  and  easily  fall,  or  he  may  start  forward,  as  if  wound  up, 
in  a  clumsy  headlong  way.  But  Ave  confess  we  are  sceptical  with  regard  to 
the  existence  of  a  special  '  cerebellar  ataxia,'  and  we  cannot  call  to  mind  any 
case  in  which  we  could  satisfy  ourselves  that  it  existed.  The  gait  of  a  child 
with  a  cerebellar  tumour  is  very  much  that  of  a  child  learning  to  walk  ;  there 
is  a  good  deal  of  clumsiness  and  a  great  readiness  to  fall,  but  this  is  clue  to 
a  weakness  or  paresis  of  the  limbs,  and  not  to  ataxia.  When  there  is  a  spastic 
rigidity,  with  an  over-action  of  the  gastrocnemius  group  and  of  the  flexors  of 
the  knee,  there  is  necessarily  a  clumsy  gait  with  a  tendency  to  fall  forward. 
We  have  never  been  able  to  satisfy  ourselves  that  in  any  given  case,  apart 
from  the  results  of  a  spastic  rigidity,  there  was  a  tendency  to  fall  on  one 
side  or  in  any  given  direction.  An  increased  tendon-reflex  is  indeed  the 
rule,  but  occasionally  it  is  certainly  absent  or  diminished.  We  cannot  give 
a  reason  for  this,  and  we  doubt  the  correctness  of  the  one  that  has  been 
given — namely,  that  it  is  due  to  a  destructive  lesion  of  the  cerebellum. 

Enlargement  of  the  head  is  common  ;  this  takes  place  early  in  young 
children  on  account  of  the  readiness  with  which  the  cranial  bones  yield  to 
the  internal  pressure,  but  it  may  take  place  also  in  children  of  six  or  seven 
years  of  age. 

Eclampsia  is  not  uncommon  ;  the  general  type  is  that  which  consists 
entirely  of  tonic  spasms  ;  there  is  retraction  of  the  head,  rigidity  of  the  limbs, 
and  frequently  opisthotonos.  Death  may  take  place  in  one  of  these  attacks 
on  account  of  the  spasms  of  the  respiratory  muscles. 

Facial  paralysis,  mostly  single  and  slight,  and  also  nystagmus,  are  among 
the  occasional  symptoms. 

In  the  later  stages,  should  the  patient  survive,  the  limbs  pass  into  a 
condition  of  semi-rigidity  ;  at  first  this  is  temporary,  but  later  it  becomes 
permanent.  The  arms  as  well  as  the  legs  are  affected,  while  the  head 
becomes  more  retracted  and  fixed.  Marked  wasting  is  certain  to  ensue  in 
the  late  stages,  and  various  trophic  changes,  such  as  sloughing  of  the  eyes 
and  bedsores,  generally  follow. 

Are  the  above  symptoms  the  result  of  a  destruction  of  a  portion  of  the 
cerebellum  ?  In  our  view  the  answer  must  be  in  the  negative  ;  they  are  the 
symptoms  produced  by  a  gradually  increasing  dropsy  of  the  ventricles,  due 
to  the  tumour  of  the  cerebellum  stretching  the  tentorium  cerebelli,  and 
obstructing  the  return  of  blood  from  the  veins  which  drain  the  ventricles, 
and  which  empty  themselves  into  the  straight  sinus.  If  the  cerebellar 
tumour  produces  any  symptoms /^r  se,  they  are  masked  by  those  produced 


TuiNonrs  of  the  Ccrebclhiiii  495 

by  the  hydrocephalus.  In  connection  with  this  we  may  bear  in  mind  that 
cases  have  been  reported  in  which  there  has  been  a  congenital  absence  of 
one  half  of  the  cerelDcllum,  and  in  which  no  symptoms  have  been  observed 
during  life.  As  a  result  of  this  obstruction  of  the  venee  Galeni,  fluid  is  pent 
up  in  the  lateral  ventricles  and  also  in  the  third  and  fourth,  and  the  sur- 
rounding parts  are  compressed.  All  the  ventricles  become  dilated,  the 
aqueduct  of  Sylvius  becomes  large  enough  to  admit  the  forefinger,  and  the 
pons  is  flattened.  The  sixth  nerves  are  compressed  beneath  the  pons,  giving 
rise  to  internal  strabismus,  and  the  facial  may  be  compressed  also.  Pressure 
of  the  fluid  on  the  motor  tracts  gives  rise  to  the  paresis  of  the  limbs  and 
consecjuently  to  staggering  gait,  and  at  a  later  stage  to  spastic  rigidity.  The 
headache  is  presumably  caused  by  the  stretching  of  the  tentorium.  Whether 
the  choked  disc  is  the  result  of  a  reflex  irritation,  or  of  a  disturbance  of  the 
circulation,  is  an  open  cjuestion.  It  is  curious  to  note  that  in  chronic  hydro- 
cephalus, where  the  large  quantity  of  fluid  is  due  to  an  excessive  secretion 
without  any  obstruction  of  the  veins,  there  is  only  exceptionally  paralysis  of 
the  sixth  nerves  and  rarely  optic  neuritis,  though  there  may  be  blindness. 
These  cases,  however,  are  either  congenital  or  commence  in  early  infancy 
before  the  sutures  have  united,  so  that  tension  is  relieved  by  the  enlargement 
of  the  skull. 

With  regard  to  the  differential  diagnosis  between  hydrocephalus,  the 
result  of  the  growth  of  a  cerebellar  tumour,  and  hydrocephalus  due  to  sub- 
acute meningitis,  or  to  a  chronic  simple  effusion,  difficulties  are  certain  to 
occur.  In  infants  or  young  children  suffering  from  enlargement  of  the  head, 
vomiting,  and  rigidity  of  the  muscles  of  the  neck  with  retraction  of  the  head, 
we  may  be  in  doubt  whether  the  child  suffers  from  a  chronic  basal  meningitis 
or  from  a  cerebellar  tumour.  In  these  cases  the  temperature  might  help, 
there  being  in  all  probability  an  evening  rise  of  a  few  degrees  in  meningitis, 
while  the  presence  of  optic  neuritis  would  favour  the  diagnosis  of  tumour. 
In  simple  effusion  the  case  is  usually  very  chronic,  and  optic  neuritis  rarely 
occurs. 

Our  experience  of  tumours  of  the  middle  lobe  of  the  cerebellum  is  very 
limited.  We  should  be  inclined  to  expect  that  the  most  prominent  symptoms 
would  be  .those  caused  by  direct  pressure  on  the  floor  of  the  fourth  ventricle. 
This  certainly  was  the  case  in  a  patient  of  our  colleague.  Dr.  H.  R.  Hutton, 
the  most  marked  symptoms  being  retraction  of  the  head  and  neck,  coming 
on  in  paroxysms  and  accompanied  by  severe  pain,  apparently  due  to  the 
cramp  of  the  muscles.  At  the  post-mortem  examination  a  cystic  tumour  of 
the  inferior  vermiform  process  was  found,  which  had  pressed  upon  and 
flattened  the  floor  of  the  fourth  ventricle. 

To  sum  up  as  regards  diagnosis.  The  symptoms  of  a  tumour  of  one  of 
the  lateral  lobes  of  the  cerebellum  are  those  of  a  gradually  increasing  hydro- 
cephalus, with  the  addition  of  optic  neuritis  and  vomiting.  It  is  only  occa- 
sionally possible  to  say  on  which  side  the  tumour  is  situated,  and  then  only 
by  means  of  the  pain,  which  may  be  referred  to  the  actual  spot.  The  so- 
called  ataxic  gait  is  due  to  paresis  or  semi-rigidity  of  the  limbs.  When  the 
tumour  occupies  the  middle  lobe  the  most  marked  symptoms  are  retrac- 
tion 0 
reflex. 


496  Diseases  of  the  Nervous  System 

Tumours  of  the  Pons  and  IVIeduIIa. — Tubercular  masses  not  infre- 
quently invade  the  pons,  being  situated  in  the  central  part,  or  small  masses 
may  be  found  in  the  floor  of  the  fourth  ventricle.  They  are  apt  to  cause 
symptoms,  less,  perhaps,  by  their  direct  pressure  effects,  as  they  grow  but 
slowly,  than  from  the  softening  which  often  surrounds  them  ;  at  the  posi- 
mortem,  when  the  size  of  the  cheesy  mass  is  discovered,  we  have  often  been 
surprised  how  little  paralysis  was  present  during  life.  Ghomas  of  the  pons 
are  not  rare  in  older  children. 

Synnptoins. — -The  combination  of  symptoms  in  disease  of  the  pons  varies 
much  in  different  cases  ;  this  is  due  to  the  close  proximity  of  the  motor 
tracts  and  the  centres  of  various  cranial  nerves.  The  paralyses  produced  by 
disease  of  the  pons  are  apt  to  be  bilateral,  on  account  of  the  right  and  left 
motor  paths  and  nerve  centres  being  near  together.  The  symptoms  vary 
according  to  the  position  of  the  lesion  in  the  pons  ;  thus  in  a  case  of  our 
own,  in  which  a  glioma  commenced  in  the  right  lower  border,  there 
was  '  crossed  paralysis,'  viz.  a  left  hemiparesis  with  pai-alysis  of  the  right 
external  rectus,  and  right  facial  paralysis,  optic  neuritis,  and  vomiting. 
Cheesy  masses  are  often  more  centrally  situated,  and  may  after  a  while 
involve  the  medulla  ;  there  may  then  be  double  facial  paralysis,  perhaps 
more  marked  on  one  side  than  the  other  ;  the  saliva  dribbles  from  the  mouth, 
the  speech  is  thick,  and  there  may  be  difficulty  in  swallowing.  There 
may  be  paresis  and  rigidity  of  the  limbs,  squint,  and  sloughing  of  the  cornea 
from  interference  with  the  fifth  nerve. 

Basal  Ganglia  and  Internal  Capsule.— Cheesy  masses  maybe  present 
in  the  caudate  or  lenticular  nucleus  or  thalamus,  but  they  only  produce  a 
definite  hemiplegia  when  they  involve  the  internal  capsule.  In  one  of  our 
own  cases  a  villous  growth  from  the  choroid  plexus  compressed  the  left 
thalamus  and  internal  capsule,  and  produced  a  paresis  of  the  right  arm  and 
leg,  with  marked  rhythmical  shaking  movements  when  voluntary  action  was 
attempted,  so  much  so  that  his  mother  said  his  arm  used  to  '  work  like  a 
clock  ; '  contractures,  facial  paralysis,  and  optic  neuritis  supervened  before 
death.  The  rhythmical  tremors  were  no  doubt  produced  by  gradual  pres- 
sure on  the  motor  path  which  passes  along  the  internal  capsule.  In  children 
there  is  rarely  loss  of  sensation  :  this  occurred,  however,  in  one  of  our  cases, 
in  which  two  large  cheesy  masses  involved  the  whole  of  the  posterior  limb  of 
the  internal  capsule,  the  arm  and  leg  of  the  opposite  side  being  contracted 
and  anaesthetic. 

Tumours  of  the  Cortical  liayer. — Irritation  of  any  part  of  the  motor 
area  of  the  cortex,  which  includes  the  ascending  frontal  and  parietal  con- 
volutions and  the  anterior  portion  of  the  superior  parietal  lobule,  gives  rise 
to  convulsions,  which  begin  in  the  arm,  leg,  or  face,  according  to  the  part 
affected.  Destruction  of  this  region,  as  by  softening  following  embolism, 
or  the  presence  of  a  tumour,  gives  rise  to  a  hemiplegia  affecting  the  face, 
arm,  and  leg,  a  partial  destruction  giving  rise  to  a  partial  paralysis.  The 
presence  of  a  syphiloma,  a  tubercular  mass,  or  pressure  by  a  tumour  growing 
from  the  membranes,  is  likely  to  give  rise  to  epileptiform  seizures,  the  con- 
vulsions starting  in  the  arm,  leg,  or  face,  though  they  are  not  necessarily 
confined  to  the  limb  in  which  they  start,  but  may  become  general.  In  the 
later  stages  a  hemiplegia  results. 


Titmoiirs  of  the  Frontal  Lobe  497 

Tumours  of  the  Trontal  l^obe  produce  no  paralysis  unless  they  encroach 
upon  the  ascending  frontal  convolution  :  in  that  case  they  may  produce  a 
paresis  of  the  leg,  arm,  and  face,  according  to  the  part  involved.  A  tumour 
involving  the  posterior  third  of  the  left  frontal  con\olution  causes  aphasia. 

Prognosis. — The  prognosis  in  cerebral  tumours  is  exceedingly  unfavour- 
able, whatever  their  nature  may  be,  unless  perhaps  syphilis  may  be  excepted. 
Undoubtedly  tubercular  masses  may  cease  to  spread  and  become  cretaceous, 
though  against  this  must  be  set  off  the  chance  that  other  masses  may  form, 
or  the  child  die  of  tubercular  meningitis  or  tubercle  elsewhere.  Every  other 
form  of  tumour  is  certain  to  progress  from  bad  to  worse.  In  the  majority 
of  cases  the  progress  is  slow,  often  lasting  over  a  year  or  more.  Death  may 
supervene  from  intercurrent  disease,  as  tubercular  meningitis,  or  other  form 
of  tubercle  ;  it  may  be  sudden  in  tumours  of  the  pons  and  cerebellum,  or  it 
may  be  exceedingly  slow,  as  in  cases  of  cerebellar  tumour  and  chronic 
hydrocephalus.  Occasionally  cases  in  which  the  diagnosis  of  tumour  is 
made  partially  recover,  or  remain  stationary  for  many  years.  Gowers 
records  a  case  of  a  girl  of  fifteen  years  who  suffered  from  hemiplegia,  head- 
ache, hemianopia,  and  optic  neuritis  of  gradual  onset  ;  she  gradually  re- 
covered, except  the  hemianopia  and  paresis  of  arm,  and  was  well,  with  these 
exceptions,  six  years  after.  In  a  case  of  a  girl  aged  ten  years,  who  was 
seen  by  the  late  Dr.  Ross  and  one  of  ourselves,  there  could  be  little  doubt 
that  there  was  a  cerebellar  tumour,  as  there  was  optic  neuritis  and  spastic 
condition  of  both  legs  ;  she  eventually  recovered  while  under  the  care  of  a 
quack,  but  became  quite  blind. 

It  is  not  uncommon  to  find  cretaceous  masses  in  the  brain,  evidently  the 
result  of  the  shrivelling  up  of  a  tubercular  mass.  This  was  so  in  the  follow- 
ing case  : 

Cheesy  Tinnoui'  of  Cerebellum ;  Temporary  Recovery. — A  boy  aged  ii  years  was 
admitted  into  hospital,  November  1881,  with  internal  squint,  optic  neuritis,  and  almost 
complete  blindness.  He  was  intelligent  and  walked  about ;  there  were  no  signs  of  any 
paralysis,  he  had  no  headache  or  vomiting  ;  during  his  stay  he  got  better,  and  was  dis- 
charged (January  1882)  apparently  in  good  health,  though,  quite  blind  from  optic  atrophy. 
He  was  re-admitted  February  1883,  having  suffered  for  six  months  with  pain  in  his  head, 
and  recently  he  had  lost  power  in  the  right  side  ;  the  right  elbow  was  semi-flexed,  the 
wrist  pronat'ed  and  flexedi  the  fingers  over-extended,  except  at  the  metacarpal  joints  ;  the 
knee  was  bent,  and  the  ankle  in  the  position  of  equino-varus  ;  there  was  also  loss  of  sen- 
sation on  the  right  side,  and  the  boy  had  some  difficulty  in  finding  the  right  arm  with  his 
left.  In  March  there  was  some  difficulty  in  swallowing,  with  paresis  of  left  side  of  face 
and  arm,  followed  by  death.  At  the  post-mortem  there  was  a  small  cyst,  with  thickened 
cretaceous  wall  on  the  inferior  surface  of  the  right  frontal  lobe,  evidently  the  remains  of 
a  tubercular  mass  ;  there  was  a  cheesy  mass  involving  the  left  caudate  nucleus  and  optic 
thalamus  and  internal  capsule  ;  there  was  a  second  cheesy  mass  involving  the  lenticular 
nucleus  and  internal  capsule  of  the  right  side.  In  this  case  there  is  no  doubt  there  was  a 
cheesy  mass  in  the  right  pre-frontal  lobe  on  the  inferior  surface,  which  gave  rise  to  optic 
neuritis  and  internal  squint,  and  which  passed  into  a  quiescent  state  ;  subsequently  other 
tubercular  masses  formed,  which,  with  a  general  tuberculosis,  caused  his  death. 

Diagnosis. — The  most  important  point  to  be  decided  is  whether  there  is 
a  cerebral  lesion,  or  the  symptoms  are  due  to  functional  disease  ;  the  question 
as  to  the  nature  and  seat  of  the  lesion  is  of  less  practical  importance.  The 
cases  which  at  first  sight  present  a  superficial  i-esemblance  to  cases  of 
cerebral  tumour  are  those  of  chronic  headaches  in  children  at  puberty,  which 

K  K 


498  Diseases  of  tJie  Nervous  System 

are  often  severe,  and  are  sometimes  accompanied  by  vomiting  or  nausea. 
The  latter,  however,  are  never  accompanied  by  optic  neuritis  or  by  sudden 
vomiting,  are  rarely  acutely  painful,  and  are  improved,  or  got  rid  of  for  a  time, 
by  active  exercise  in  the  open  air.  The  headaches  of  a  cerebral  tumour  are 
severe,  sometimes  make  the  patient  scream  with  pain,  and  are  made  worse 
by  active  exercise. 

The  vomiting  in  a  case  of  cerebral  tumour  is  erratic  ;  it  may  come  on  the 
first  thing  in  the  morning,  is  perhaps  constant  for  a  day  or  two  or  more, 
then  passes  away  for  awhile  without  any  apparent  reason.  The  paralyses 
of  hysteria  are  not  often  hemiplegic,  being  more  often  paraplegic,  and  are 
never  accompanied  by  optic  neuritis. 

When  fits  are  present  there  may  be  a  difficulty  in  distinguishing  between 
epilepsy  and  a  tumour,  especially  as  a  hemiparesis  is  apt  to  remain  after  a 
fit.  In  these  cases,  if  the  convulsions  have  constantly  a  local  commencement, 
they  are  probably  due  to  a  tumour,  and  later  on  optic  neuritis  or  some 
paralysis  would  decide  the  diagnosis.  The  presence  of  more  tumours  than 
one  may  make  the  differential  diagnosis  difficult. 

Treatment. — Except  in  the  case  of  syphilomas  of  the  brain,  the  treatment 
of  cerebral  tumours  by  medicines  resolves  itself  into  a  treatment  of  symptoms. 
Wherever  there  is  the  least  chance  of  the  tumour  being  syphilitic,  iodide  of 
potassium  should  be  given  in  full  doses,  though  in  children  gummatous  disease 
of  the  brain  is  rare.  If  it  is  supposed  that  the  tumour  is  tubercular,  cod- 
liver  oil  and  iodide  of  iron  may  be  prescribed,  while  the  child  is  kept  at  rest, 
and  placed  under  the  most  careful  hygiene. 

For  the  headaches,  bromides,  Indian  hemp,  and  opium  may  have  to  be 
prescribed.  The  vomiting,  Avhich  is  so  often  troublesome,  must  be  treated 
by  perfect  rest  in  bed,  peptonised  milk  or  iced  drinks  being  given  in  small 
quantities.  Hydrocyanic  acid  may  be  given.  The  vomiting  is  exceedingly 
erratic,  coming  and  going  without  any  apparent  cause.  In  some  tumours  at 
least  the  question  of  operation  may  be  entertained  (see  infra). 

Ceretoral  Abscess. — In  children,  as  in  adults,  the  common  cause  of 
abscess  of  the  brain  is  injury  or  ear  disease  ;  less  often  it  is  the  result  of 
suppuration  in  a  distant  part,  as  an  empyema  or  abscess  of  lung.  Abscess 
is  most  common  in  the  cerebrum,  less  frequent  in  the  cerebellum  or  pons. 

Syinptojiis. — The  early  symptoms  are  those  more  or  less  of  meningitis, 
namely  headache,  fever,  vomiting,  and  perhaps  convulsions  ;  they  may,  how- 
ever, be  very  slight  and  readily  overlooked.  The  later  symptoms,  those  of  the 
chronic  stage,  vary  according  to  the  seat  of  the  abscess,  and  are  more  or  less 
those  of  a  cerebral  tumour,  including  optic  neuritis,  headache,  vomiting, 
convulsions,  and  varying  paralyses,  also  perhaps  hectic,  and  emaciation.  The 
diagnosis  of  abscess  from  meningitis  or  tumour  is  sometimes  very  difficult, 
as  the  following  cases  show.  A  girl  of  two  years  of  age,  who  was  admitted 
into  hospital  under  Dr.  Hutton,  had  had  a  discharge  from  her  right  ear  for 
three  months,  but  was  otherwise  well  and  strong,  till  fourteen  days  before 
admission,  when  she  had  a  right-sided  convulsion  lasting  four  hours,  followed 
by  unconsciousness  ;  four  days  afterwards  she  had  a  similar  attack  :  she 
squinted,  and  was  more  or  less  bHnd  after  it.  On  admission  there  was 
almost  complete  motor  and  sensory  paralysis  of  the  right  arm  and  leg,  with 
loss  of  sensation  on  the  left  side  of  the  face  and  ptosis  on  the  left ;  she  became 


Cerebral  Abscess  499 

convulsed,  the  convulsions  beginning  in  the  right  side,  and  was  unconscious 
before  death,  At  the  post-mortem  an  abscess  cavity  was  found  in  the  left 
temporo-sphenoidal  lobe,  extending  into  the  occipital  lobe  and  reaching  the 
internal  capsule  :  it  contained  three  ounces  of  pus.  The  left  tympanum  was 
full  of  pus.  In  the  following  case  the  abscess  followed  a  perforating  wound 
of  the  orbit.  Aboy  aged  six  years  was  playing  in  a  hayfield  when  by  accident 
he  was  wounded  above  the  left  eye  with  the  prong  of  a  hayfork  ;  the  eye 
swelled,  but  no  external  wound  was  found.  During  the  next  few  weeks  he 
was  irritable  and  frequently  vomited.  Six  months  after  he  was  brought  for 
advice,  as  his  sight  was  failing.  On  admission  he  was  cjuite  blind  (atrophy 
of  discs)  and  somewhat  dull  of  comprehension  ;  he  could  walk  well  ;  the  right 
hand  was  weak,  but  not  paralysed ;  he  remained  much  the  same  for  a  month, 
when  he  died  suddenly.  At  the  post-Diortcni  the  left  frontal  lobe  was  larger 
than  that  of  the  opposite  side,  its  convolutions,  including  the  superior,  middle, 
and  inferior,  with  more  or  less  of  the  ascending  frontal  and  parietal,  flattened  ; 
its  inferior  surface  was  adherent  to  the  orbital  plate  and  of  a  yellow  tinge  ; 
and  there  was  an  abscess  containing  four  or  five  ounces  of  greenish  pus.  It 
was  clear  there  had  been  a  penetrating  wound  through  the  orbital  plate  into 
the  brain. 

Treatment. — When  pus  has  formed  there  is  little  hope  in  any  method  of 
treatment,  except  operation. 

Surgical  Treatment  of  Cerebral  Lesions. — Our  knowledge  of  the  operative 
treatment  of  tumours  of  the  brain  is  still  very  limited,  but  enough  has  been 
learnt  to  justify  a  short  account  of  the  subject  being  given  here.  At  pi-esent 
only  those  growths  which  lie  on  or  near  the  surface  of  the  cerebrum  have 
been  successfully  dealt  with  ;  tumours  at  the  base  of  the  brain,  or  involving 
the  basal  ganglia,  may  be  looked  upon  as  inaccessible  to  surgery  at  present, 
and,  though  cerebellar  growths  are  not  beyond  our  reach,  but  little  has  yet 
been  done  for  their  removal.  Surgery  chiefly  deals  with  growths  situated  in 
the  motor  area  of  the  cortex,  since  the  localisation  of  the  tumour  is  most 
satisfactorily  to  be  made  out  in  this  region.  Again,  only  those  growths 
which  are  of  limited  size  are  suitable  for  removal,  since  the  destruction  or 
disturbance  of  large  areas  of  the  brain  would  lead  to  as  great  evils  as  the 
tumour  itself.  Assuming"  that  the  presence  and  exact  position  of  a  tumour 
have  been  ascertained  by  the  symptoms  presented,  the  following  are  the 
steps  to  be  taken  for  its  removal.  If  time  permits,  at  least  twenty-four  hours 
should  be  devoted  to  preparation  of  the  patient  for  the  operation.  The 
entire  scalp  should  be  shaved  and  thoroughly  cleansed  with  turpentine  ;  after 
this  a  compress  soaked  in  solution  of  corrosive  sublimate,  i  in  3,000,  or 
carbolic  acid,  i  in  40,  should  be  kept  applied  to  the  head  for  an  hour  before 
operation.  The  utmost  precautions  should  be  taken  to  have  all  instruments, 
and  anything  likely  to  come  into  contact  with  the  field  of  operation,  thoroughly 
aseptic.  After  the  child  has  been  anaesthetised,  a  large  flap  of  integument, 
having  its  centre  over  the  seat  of  the  tumour,  should  be  reflected  and  the 
bone  laid  bare.  Next  a  large  circle  of  bone  should  be  removed  with  a  trephine 
or  gouge,  or  saw,  and  the  dura  mater  exposed  :  the  opening  must  then  be 
enlarged  by  cutting  forceps  or  saw  as  may  be  required.  All  bleeding  must  be 
arrested.  The  surface  of  the  dura  mater  should  then  be  carefully  examined 
as  to  its  colour,  as  to  the  presence  of  pulsation,  and  as  to  any  tendency  to 

K  K  2 


500  Diseases  of  the  Nei^ous  System 

protrusion  through  the  aperture  in  the  skull.  We  have  noticed  in  a  case  of 
cerebral  tumour  thinning  of  the  bone  over  the  seat  of  the  growth,  with  en- 
gorgement of  the  diploic  vessels,  but  this  can  only  be  expected  to  be  seen 
when  the  growth  is  large  and  superficial.  Should  the  tumour  be  extra-dural, 
its  removal  may  be  now  accomplished  ;  but  if  it  is  truly  cerebral,  a  crucial 
incision  should  be  made  in  the  membrane,  and  the  surface  of  the  brain 
inspected  and  felt  with  the  finger  for  evidence,  either  visible  or  palpable,  of 
the  mass  ;  if  the  growth  is  seen,  its  size  and  connections  should  be  studied, 
and  the  question  of  the  possibility  of  its  removal  decided  upon.  If  it  is 
determined  to  proceed  with  the  operation,  the  substance  of  the  cortex  must 
be  separated  from  the  growth,  and  the  mass  removed  with  as  Httle  injury 
as  possible,  both  to  brain  substance  and  to  the  vessels  of  the  part.  If  there  is 
softening  (encephalitis)  of  the  brain  round  the  growth,  the  prognosis  is  bad, 
but  any  actually  disintegrated  brain  should  be  removed.  All  bleeding  is  then 
to  be  arrested,  the  dura  mater  sutured  over  the  bi'ain,  and  the  portion  of  skull 
removed,  which  should  have  been  kept  lying  in  warm  carbolic  lotion  (i  in  80), 
may  be  cut  up  into  pieces  about  the  size  of  canary  seed,  and  replaced  on  the 
surface  of  the  membrane  ;  or  the  whole  disc  of  bone  may  be  replaced  entire  ; 
even,  however,  if  the  bone  is  not  replaced,  the  gap  is  largely  filled  up  by 
bone.  In  some  cases,  of  course,  it  is  desirable  to  have  the  aperture  yielding, 
so  that  it  may  give  way  before  increased  intra-cranial  pressure.  Provision 
may  be  made  for  drainage,  or  the  wound  may  be  closed  and  dressed  anti- 
septically  in  the  ordinary  fashion.  After  the  operation  the  child  is  kept 
absolutely  quiet  in  bed,  and  fed  on  weak  animal  broths  and  diluted  milk  in 
small  quantities.  If  the  case  is  doing  well,  there  will  be  no  need  to  disturb 
the  dressings  for  a  week  or  ten  days,  when  the  wound  will  be  found  healed, 
with  the  exception  of  the  drain  opening.  Should  no  growth  be  found,  or 
should  there  be  very  extensive  encephalitis,  or  if  the  tumour  be  too  extensive 
for  removal,  the  operation  must  be  abandoned.  Such  are  briefly  the  general 
rules  to  be  adopted  in  dealing  with  brain  tumours,  and  a  large  part  of  the 
description  will  also  apply  to  operations  for  cerebral  abscess,  or  for  those 
cortical  lesions  which  give  rise  to  epilepsy  or  other  troubles  and  necessitate 
surgical  measures.  A  few  additional  remarks  may  be  made  on  the  two  last- 
mentioned  subjects.  As  to  cerebral  abscess,  it  is  the  result,  apart  from 
tuberculosis,  most  commonly  of  injury  or  disease  of  the  ear  ;  in  the  case  of 
traumatic  abscess  the  seat  of  the  abscess  will  usually,  though  not  always, 
correspond  with  the  seat  of  the  external  injury,  though  this  guide  should  be, 
of  course,  supplemented  by  the  indications  given  by  any  paralyses  that  may 
be  present.  The  steps  of  the  operation  are  those  already  described  ;  should^ 
however,  no  evidence  of  the  abscess  be  seen  on  exposing  the  brain,  careful 
systematic  exploration  to  a  depth  of  from  one  to  two  inches  should  be  made 
in  every  direction  from  the  centre  of  the  part  exposed.  This  is  best  done 
with  a  grooved  needle,  fine  trochar  and  cannula,  or  director.  Should  pus  be 
found,  the  opening  must  be  enlarged  and  the  abscess  cavity  drained,  and  the 
operation  completed  as  above  described.  (For  further  details  of  cerebral 
abscess,  the  result  of  otitis,  vide  chapter  on  Diseases  of  the  Ear.) 

Where  trephining  is  done  for  Jacksonian  epilepsy,  it  must  be  remembered 
that  pressure  or  irritation  may  be  due  to  a  depressed  or  thickened  portion  of 
bone,  to  a  local  pachymeningitis,  or  to  a  cicatrix,  or  to  local  inflammation  of 


Cerebral  Hemorrhage  501 

the  cortex  of  the  brain  itself.  If  the  irritant  is  cranial,  the  ofteniliny  bone 
must  be  removed.  So  also,  if  a  local  thickening  of  the  dura  mater  is  found, 
it  should  be  excised.  If,  however,  the  lesion  is  in  the  brain  itself,  the  ques- 
tion arises  whether  it  is  so  extensi\-e  that  removal  of  the  injured  part  can  be 
effected  without  an  extent  of  paralysis  following  which  would  render  the 
patient's  condition  worse  than  it  already  is.  The  details  of  the  operation  are 
the  same  as  in  the  case  of  tumour  or  abscess.  For  further  information  we 
must  refer  to  the  papers  of  Dr.  Macewen,  Mr.  Horsley,  and  others.  There 
is  no  doubt  that,  on  the  one  hand,  the  brains  of  children  are  more  tolerant  of 
operation  than  those  of  adults,  and,  on  the  other  hand,  that  brain  lesions 
which  would  pro\e  fatal  to  adults  are  not  only  recovered  from  in  children, 
but  may  leave  little  or  no  permanent  effects,  even  if  left  to  nature.  Each 
case  must  be  judged  on  its  merits. 

The  dangers  of  hernia  cerebri  and  diffuse  encephalitis  or  meningitis  are 
no  doubt  considerable,  but  with  thorough  antisepticism  these  risks  may  be 
generally  avoided.  It  has  been  shown  by  Dr.  Alacewen  that  hernia  cerebri, 
though  it  may  result  from  imperfect  wound  management,  may  also  be  due  to 
a  pi'e-existing  encephalitis,  even  in  the  absence  of  any  septic  condition  of  the 
wound.  Should  hernia  cerebri  appear,  it  is  best  dealt  with  by  pressure 
applied  over  the  wound  by  means  of  a  plate  of  sheet-lead  laid  outside  the 
inner  layer  of  dressings. 

The  subject  of  operative  measures  in  disease  and  injury  to  the  spinal 
cord  is  still  more  in  its  infancy  than  is  that  of  cerebral  surgery,  and  no  definite 
rules  can  be  laid  down  ;  some  account  of  the  matter  will  be  found  under  the 
head  of  Spinal  Caries  and  Spina  bifida. 

It  must  be  looked  upon  at  present  as  a  much  more  serious  matter  to  open 
the  spinal  theca  than  to  incise  the  dura  mater  ;  hence  greater  hesitation 
should  be  felt  in  dealing  with  cases  requiring  so  severe  a  measure. 

Cerebral  H8einorrhag;e 

We  have  already  remarked  (p.  19)  that  cerebral  hccmorrhage  occurring 
in  early  life  is  hardly  ever  the  result  of  a  ruptured  artery.  Hccmorrhage 
does,  however,  not  infrequently  take  place  from  the  venous  capillaries  on  the 
surface  of  the  brain,  and  also,  though  in  less  degree,  into  the  grey  and  white 
matter.  The  pia  mater  and  its  capillaries  are  exceedingly  delicate  in  the 
infant,  and  when  distended  with  hypervenous  blood,  as  during  some  inter- 
ference with  the  respiration,  they  are  exceedingly  liable  to  rupture  or  to  allow 
the  blood  to  ooze  through  their  walls.  Hypervenous  blood  appears  more 
readily  to  escape  from  the  vessels  by  oozing  than  does  ordinary  blood. 
Meningeal  bleedings  of  a  larger  or  smaller  amount  are  constantly  found  in 
infants  who  have  been  born  asphyxiated,  or  who  only  survive  their  births  a  few- 
days  in  consequence  of  feeble  respiratory  powers  (see  fig.  5).  The  same  con- 
dition is  seen  in  infants  who  have  been  '  overlain  in  bed,'  and  in  those  who 
have  died  in  convulsions.  Clots  of  various  sizes  may  also  be  found  in  the 
central  white  matter,  in  the  internal  capsule,  and  in  the  masses  of  grey  matter 
at  the  base  of  the  brain.  The  younger  the  infant  the  greater  will  be  the 
brain  damage  done  by  the  bleeding,  as  the  brain  is  exceedingly  soft  at  birth 
and  easily  injured  ;  the  more  immature   the  brain,  the  more  is  its  develop- 


502 


Diseases  of  the  Nervous  System 


ment  likely  to  be  interfered  with.  As  the  result  of  the  brain  damage 
there  may  be  hemiplegia,  diplegia,  paraplegia,  or  idiocy,  with  or  without 
paralysis.  The  paralyses  which  date  from  cerebral  haemorrhage  at  birth 
are  mostly  more  severe  than  those  which  follow  haemorrhages  in  older 
children.  Cerebral  haemorrhage  apart  from  a  meningeal  bleeding,  when  it 
occurs  during  early  life,  takes  place  in  '  bleeders,'  and  often  as  the  result 
of  a  blow. 


Fig.  103. — Spastic  Paralysis,  the  result  of 
Meningeal  HEemorrhage  at  Birth.  Willie 
G.,  aged  8  years.  The  weight  of  the  hodj' 
is  partly  supported  by  being  held  up  by  the 
arms,  partly  by  resting  on  the  toes. 


Fig.  104. — Willie  G.,  after  division  of  the 
tendo  Achillis  and  forced  dorso-flexion. 


Post-partum  IVIeningeal  Haemorrhage.  Birth  Palsy. — A  delayed 
labour  from  any  cause  is  Hable  to  give  rise  to  asphyxia,  the  vessels  of  the  pia 
mater  being  gorged  with  dark  venous  blood,  and  a  leakage  takes  place,  the 
blood  oozing  from  the  distended  vessels.  The  damage  done  by  the  pressure 
of  the  clot  forming  on  the  convex  surface  of  the  brain  may  be  sufficient  to 
permanently  injure  the  cortical  motor  or  other  cortical  centres.  The  newly 
born  infant's  brain  is  exceedingly  soft  and  readily  injured,  as  anyone  knows 
who  has  attempted  to  remove  on^  post  mortem  without  damage;  if  the 
slightest  injury  is  done  to  the  brain  by  the  saw  in  dividing  the  skull,  the 


Post-partinn  Meningeal  Hcsmorrhage  503 

brain  substance  will  ooze  out  of  the  saw-cut  almost  like  clotted  cream.  Now, 
not  only  may  considerable  damage  be  done  to  the  brain  by  a  comparatively 
small  surface  haemorrhage,  but  as  the  cortical  centres  are  imperfectly  de\-eloped 
at  birth,  the  pressure  of  a  clot  or  a  rupture  of  the  grey  matter  may  readily 
prevent  growth  and  de\elopment.  The  consequences  of  this  brain  damage 
are  various,  but  are  often  not  very  apparent  for  some  months  or  more 
after  birth.  The  mental  powers  may  never  properly  develop,  though 
the  limbs  are  strong,  and  the  child  is  mentally  weak  or  an  idiot ;  or  the 
lower  extremities  are  stiff  and  weak,  or  there  is  a  paresis  of  hemiplegic 
distribution,  the  child  generally  alSo  being  mentally  deficient.  In  all  a  history 
of  a  prolonged  labour,  or  of  being  '  born  blue,'  can  be  obtained. 

A  whole  family  is  often  more  or  less  affected  when  the  mother  has  a 
narrow  pelvis,  or  for  various  reasons  has  difficult  labours  ;  some  of  the 
infants  may  escape  if  born  before  they  are  fully  developed.  First-borns  are 
apt  to  suffer  the  most,  as  can  be  readily  understood. 

The  following  history  of  a  family  may  form  an  illustration  of  the  damage 
which  may  be  done  by  difficult  labours.  Mrs.  G.  has  always  difficult  labours 
in  consequence  of  a  narrow  pelvis.  She  has  had  seven  children  born  at  or 
near  full  time. 

1.  Willie,  eight  yeai-s  old,  suffers  from  spastic  paraplegia  and  is  mentally 
deficient  (figs.  103  and  104).     (An  inmate  of  the  Royal  Albert  Asylum.) 

2.  John  died  at  thirteen  months,  of  convulsions  ;  '  head  never  was  right.' 

3.  Clara,  six  years,  is  all  right. 

4.  Baby,  died  soon  after  birth. 

5.  Baby,  born  dead. 

6.  Boy,  two  years  old,  is  all  right. 

7.  Girl,  four  months  old,  both  legs  semi-rigid,  exaggerated  tendon 
reflexes,  ankles  rather  stiff. 

In  this  family  of  seven,  two  appear  to  have  escaped  uninjured  ;  of  the 
remaining  five,  two  are  living,  having  sustained  a  brain  damage,  and  three 
are  dead,  their  death  no  doubt  being  directly  due  to  a  birth-injury  to  the 
brain. 

Symptoms. — -The  most  common  symptom  which  immediately  follows 
the  meningeal  haemorrhage  is  convulsions ;  sometimes  there  is  paralysis, 
and  there  may  be  rigidity.  In  the  great  majority  of  the  cases  there  is  no 
marked  paralysis  immediately  following  birth,  or  at  any  rate  it  escapes  the 
mother's  attention,  and  it  is  only  at  the  end  of  the  first  year  that  it  is  noticed 
there  is  stiffness  about  the  child's  legs,  which  prevents  it  from  walking  or 
from  making  any  attempts  to  walk.  Mostly,  however,  when  the  infant  is  a 
few  months  old,  a  careful  examination  of  the  lower  extremities  will  reveal  an 
exaggerated  knee-reflex  and  a  stiffness  of  the  ankle  joints.  In  some  cases 
there  is  over-action  of  the  adductors  of  the  thighs,  so  that  the  legs  are  con- 
stantly crossed,  with  probably  also  more  or  less  talipes  equino-varus.  Both 
arms  may  be  affected,  or  an  arm  and  leg  only  ;  there  is  usually  backwardness 
in  talking.  When  the  symptoms  are  fully  developed,  as  they  usually  are  at 
two  or  three  years  of  age,  the  rigidity  of  the  limbs,  most  frecpently  the  legs, 
is  very  characteristic;  there  is  '  spastic  paraplegia.'  In  a  severe  case  the 
child  cannot  walk  or  stand  unaided,  and  lies  helplessly  in  bed  ;  the  knees  are 
semi-flexed,  with  adductor  spasm,  the  tendo  Achillisis  drawn  up,  so  that  the 


504 


Diseases  of  the  Nervous  System 


foot  is  in  a  position  of  equino-varus,  there  is  exaggerated  knee-reflex,  and 
ankle  clonus.  In  some  instances  the  child,  though  unable  to  stand  or  walk 
without  help,  on  account  of  the  talipes  equinus  present,  can  crawl,  and  may 
learn  to  do  this  fairly  well ;  this  was  the  case  with  Willie  G.  (see  fig.  103). 
This  condition  may  remain  throughout  life,  and  occasionally  adults  belong- 
ing to  this  class  may  be  seen  crawling  on  all  fours  in  the  streets,  and  gaining 
their  livelihood  by  begging. 

Many,  perhaps  the  majority  of  cases,  learn    to  walk  in  some  sort  of  a 
fashion,  but  with  difficulty,!, on  account  of  the  spasm  of  the  gastrocnemii  and 

the  consequent  tendency  there  is  to  fall 
forwards,  and  the  awkwardness  and 
want  of  control  over  their  movements. 
The  arms  are  more  rarely  affected 
than  the  legs  ;  sometimes  there  is 
slight  rigidity  in  one  only  or  in  both, 
which  interferes  with  their  use,  or  the 
elbow  is  flexed,  the  wrist  flexed  and 
pronated,  and  the  fingers  flexed  at  the 
metacarpo-phalangeal  joints.  There 
may  be  present  the  irregular  move- 
ments known  as  athetosis  (see  p.  508). 
Sometimes  there  is  slight  facial  para- 
lysis, only  noticeable  when  the  child 
laughs  or  cries  ;  we  have  never  seen 
it  well  marked. 

The  child  is  usually  backward  in 
talking,  and  in  some  cases  where  the 
mental  defect  is  marked  they  never 
can  utter  anything  but  meaningless 
sounds.  The  mental  condition  varies  ; 
sometimes  there  is  complete  idiocy, 
more  often  some  loss  of  intelligence, 
or  the  child  is  emotional,  being  easily 
roused  to  anger,  and,  if  going  to  school, 
is  teased  and  tormented  by  its  com- 
panions. The  shape  of  the  head  is 
often  unaltered  ;  occasionally,  it  is 
small  and  more  or  less  flattened  in 
the  parietal  regions  (see  fig.  105). 
Cerebral  Haemorrliag'e  occurring'  after  Birth.  Acute  Cerebral 
Palsy. — Cerebral  heemorrhage  may  occur  from  various  causes  besides  those 
in  operation  during  the  act  of  birth.  Blood  may  ooze  on  to  the  surface  of 
the  brain  or  into  the  white  or  grey  matter  during  over-distention  of  the 
cerebral  veins  from  any  cause.  The  commonest  cause  is  a  series  of  con- 
vulsions. Hcemorrhagemay  occur,  however,  during  whooping  cough,  or  in 
severe  vomiting,  or  in  any  cases  in  which  there  is  a  severe  venous  congestion 
of  the  brain.  We  have  several  times  seen/cj/"  mortem  a  meningeal  bleeding 
in  infants  who  have  died  in  convulsions,  and  also  after  whooping  cough. 
Such  haemorrhages  are  most  common  during  the  first  two  years  of  life — 


'Birth  Paralysis,  Spastic  Paraplegia, 
Mental  Feebleness. 


Cerebral  IlicmorrJiage  505 

indeed,  they  are  uncommon  at  any  other  period,  and  this  is  to  be  expected 
when  we  rememlDer  how  much  more  dehcate  the  capiUarics  and  cerebral  veins 
are  during  infancy  than  in  hiter  hfe. 

The  convulsions  which  immediately  precede  the  hicmorrhage  may  be 
the  result  of  many  different  conditions.  Sometimes  the  primary  illness  is 
measles,  acute  diarrhoea,  pneumonia,  whooping  cough,  or  scarlet  fever  ;  more 
often,  perhaps,  the  attack  cannot  be  referred  to  any  one  of  these,  and  the 
principal  symptoms  are  high  fever  and  drowsiness,  and  then  the  convulsions 
supervene  ;  then,  after  a  series  of  convulsions,  a  more  or  less  well-marked 
hemiplegia  is  noted.  Such  cases  are  often  looked  upon  as  '  brain  fever '  or 
'  congestion  of  the  brain.'  In  some  cases  there  is  a  history  of  a  fall.  In  other 
cases  the  convulsions  are  undoubtedly  reflex,  especially  from  colic.  A  high 
temperature,  105°  to  106°,  seems  to  excite  convulsions. 

In  all  cases  we  have  noted  the  convulsions  were  severe,  often  one-sided 
at  first,  but  tending  to  become  general  ;  they  may  last  from  a  few  hours  to  a 
week  ;  the  infant  may  remain  a  long  time  in  a  state  of  coma.  Probably  a 
small  amount  of  bleeding  may  take  place  without  producing  any  symptoms, 
and  absorption  takes  place  and  no  ill  effect  remains.  In  others  there  may 
be  a  slight  and  transient  paresis  of  an  arm  or  leg  or  both,  such  as  is  sometimes 
seen  after  an  epileptic  fit.  In  another  class  no  paralysis  is  left,  but  the  child 
grows  up  with  feeble  mental  powers  which  date  from  the  time  of  the  con- 
vulsions. In  a  common  class  of  case  a  more  or  less  complete  hemiplegia  or 
diplegia  is  left,  with  perhaps  more  or  less  facial  paralysis. 

As  an  instance  of  reflex  convulsions  giving  rise  to  cerebral  haemorrhage 
we  may  relate  the  following  case  : 

Convulsions;  Cerebral  hcsmorrhage. — George  L.,  aged  12  years,  was  brought  to  the 
Children's  Hospital,  Manchester,  suffering  from  tuberculosis  and  also  hemiplegia ;  his 
mother  gave  the  following  history.  He  was  strong  and  healthy  when  born,  though  the 
labour  was  somewhat  tedious.  There  was  no  history  of  hereditary  syphilis.  He  walked 
at  twelve  months  of  age,  and  was  well  and  strong  till  two  years  of  age.  At  this  time  he 
had  a  fit,  which  was  attributed  to  his  eating  some  crust  of  apple  pie  some  half  an  hour 
before  the  attack.  He  was  playing  on  the  doorstep  at  the  time  ;  he  suddenly  became 
'  black  about  the  mouth,'  and  would  have  fallen  but  for  another  boy  who  caught  him  in 
his  arms.  .The  fit,  including  the  unconscious  state  which  followed,  lasted  about  ten 
minutes.  Two  weeks  after  he  had  another  fit,  which  lasted  half  an  hour,  and  was  more 
severe  than  the  first ;  his  right  arm  and  leg  were  especially  convulsed.  After  this  fit  it  was 
found  that  his  right  arm  hung  useless',  and  in  trying  to  walk  he  dragged  the  right  leg. 
The  face  was  unaffected.  The  arm  was  always  worse  than  the  leg  ;  at  first  he  could  not 
hold  anything  in  it.  Both  arm  and  leg  slowly  improved,  but  have  remained  more  or  less 
stiff  and  rigid.  Ever  since  the  first  convulsion  he  has  been  subject  to  fits,  but  he  has  not 
had  any  for  the  last  two  years.  He  has  had  on  an  average  two  fits  a  week,  from 
two  years  of  age  till  he  was  ten  years.  They  only  lasted  some  minutes,  accompanied  by 
loss  of  consciousness  ;  he  always  knew  when  a  fit  was  coming  on  by  his  right  thumb  begin- 
ning to  '  work.'  He  used  to  say,  '  Mother,  my  thumb's  working  ; '  then  he  would  fall  over 
almost  immediately  if  not  caught.  The  fits  were  mostly  right-sided,  but  the  left  arm  and 
leg  would  also  '  work.'  Lately  he  has  used  his  right  arm  more  than  formerly,  being  able 
to  hold  things  in  it. 

When  examined  (September  8,  1890)  it  was  evident  he  was  affected  with  an  old 
hemiplegia  :  he  could  walk,  but  dragged  his  right  leg  after  him.  He  could  use  his  right 
arm  for  holding  things,  but  could  not  feed  himself  with  it ;  the  shoulder  joint  was  fairly 
movable,  the  elbow  bent  and  semi-rigid,  and  the  hand  pronated ;  the  stiffness  could  be 
overcome  by  slight  force.     The   right  leg   was  somewhat  stiff  at  the  knee  and  slightly 


5o6 


Diseases  of  the  Nervous  System 


flexed  as  he  lay  in  bed,  with  die  foot  pointed.     There  was  exaggerated  knee  reflex  on  the 
right  side.     There  was  no  evidence  of  any  mental  weakness. 

He  died  of  tuberculosis  in  February  1891.  The  post-mortem  was  made  by  Mr.  R.  O. 
Bowman,  senior  resident  medical  officer  at  the  Children's  Hospital;  we  examined  the 
brain  next  day.  An  examination  of  the  outer  surface  of  the  brain  showed  it  to  be  per- 
fectly normal,  the  membranes  \\<tx&  healthy,  there  was  no  flattening  of  the  convolutions  or 
any  evidenctJ  of  an  old  surface  haemorrhage.  The  internal  parts  were  examined  by  making 
transverse  sections.  The  first  section  taken  through  the  centrum  ovale  showed  nothing 
abnormal.  A  section  made  exposing  the  lateral  ventricles,  without  slicing  the  corpus 
striatum,  showed  an  old  cyst  (fig.  106,  a)  with  brownish  contents,  |  inch  in  length, 
situated  on  the  left  side  in  the  white  substance  between  the  fissure  of  Rolando  and  the 
corpus  striatum  ;  and  four  small  cysts  B  B  situated  on  the  right  side  in  the  white  substance. 


Fig.  106. — Horizontal  Section  of  Brain,  exposing  lateral  ventricles  (  x  |).  f  r,  fissure  of 
Rolando  ;  a,  old  blood  cj'st  ;  B,  B,  B,  B,  small  blood  cysts.  Haemorrhage  at  two  years 
of  age  ;  death  at  twelve  j-ears  of  age. 


The  cyst  marked  A  was  apparently  about  \  inch  in  depth.  There  was  no  sclerosis  or 
induration  in  the  neighbourhood  of  the  cysts.  A  third  section  made  lower  than  the  above, 
and  on  a  level  with  the  upper  surface  of  the  cerebellum,  and  slicing  the  optic  thalamus, 
caudate  nucleus,  and  internal  capsule  (fig.  107),  showed  the  lower  limit  of  the  cysX.  seen  in 
fig.  106,  a  second  old  blood-cyst  b,  and  another  small  one  at  C.  Another  similar  cyst  was 
found  in  the  white  substance  of  the  frontal  region  at  a  lower  level  than  fig.  107. 

Sections  of  the  cord  made  in  the  cervical,  dorsal,  and  lumbar  regions  did  not  show 
any  sclerosis  or  wasting  of  the  descending  tracts  ;  neither  was  there  any  wasting  of  the 
internal  capsule  or  crura. 

In  reviewing  the  history  of  the  case,  in  the  hght  of  the  morbid  anatomy, 
there  is  much  reason  to  beheve  that  a  multiple  hemorrhage  took  place  when 


Cerebral  Hceviorrhaoe 


507 


the  boy  was  two  years  of  age,  and  that  one  or  more  (a,  fig.  106;  of  the 
Inemorrhages  gax'e  rise  to  the  paralysis  by  the  destruction  of  some  of  the 
white  fibres  en  route  from  the  motor-surface  centres  to  the  internal  capsule. 
There  seems  to  Ije  little  room  for  douljt  that  the  initial  convulsions  were  the 
cause  and  not  the  consequence  of  the  multiple  haemorrhages.  It  is  hardly 
conceivable  that  the  multiple  hitmorrhages  should  be  caused  by  any  throm- 
bosis, embolism,  or  ai'teritis  ;  they  must  presumably  have  been  due  to  a 
sudden  engorgement  of  the  veins  due  to  asphyxia,  such  as  takes  place  in  a 
fit  in  consecjuence  of  spasm  of  the  respiratory  muscles. 

As   an  example  of  a  hemiplegia   following  convulsions  associated  with 
measles  the  following  case  occurring  in  a  healthy  boy  of  twenty  months,  a 


Fig.  107. — Horizontal  Section  through  Brain  at  a  lower  level  than  fig.  io6,  showing  Optic 
Thalamus  and  Caudate  Nucleus  ( x  i).     a,  b,  c,  old  blood  C5'sts. 

patient  of  Mr.  Wilson  of  Cheadle,  which  came  under  our  observation,  may 
be  taken  as  an  example.     Mr.  Wilson's  notes  are  as  follow  : 


Measles  ;  Pneumonia  ;  Convulsions  ;  Hemiplegia. — Boy,  twenty  months.  The  measles 
rash  was  first  noticed  on  May  10 ;  convulsions  commenced  at  noon  on  the  nth  :  these 
consisted  of  clonic  spasms  of  the  right  arm  and  leg  and  right  side  of  the  face ;  the  eyes 
were  turned  to  the  right  side  and  fixed  ;  the  pupils  were  dilated,  the  temperature  rose  to 
105°,  the  pulse  was  too  fast  to  be  counted  ;  the  convulsions  continued  during  the  morning  ; 
at  I  P.M.  the  temperature  was  io7°F. ,  when  the  patient  was  put  into  a  cold  bath  ;  it  was 
again  107°  at  4  p.m.,  when  he  was  bathed  again  and  five  grains  of  quinine  given  by  the 
rectum  ;  at  this  time  an  examination  of  the  lungs  showed  pneumonia  at  one  base  ;  at  6  p.m. 
the  temperature  was  103^,  and  the  mother  noticed  he  had  lost  the  use  of  his  left  side  ;  at 


5o8  Diseases  of  the  Nervous  System 

8  P.M.  it  was  noticed  that  the  left  arm  was  completely  flaccid,  paralysed,  and  apparently 
anaesthetic  ;  the  leg  was  rigid,  but  on  tickling  the  sole  of  the  foot  the  toes  moved  slightly. 
Pneumonia  developed  the  ne.xt  day  ;  the  child  died  on  the  13th,  the  arm  and  leg  remaining 
in  the  same  condition  ;  unfortunately,  no  autopsy  could  be  obtained.  The  paralysis  was 
probably  due  to  a  surface  bleeding  following  the  convulsions. 

The  following  case  may  be  given  as  illustrative  of  one  which  recovered 
from  the  immediate  effects  of  the  acute  attack  : 

Convulsions ;  Hemiplegia. — A  child  of  thirteen  months,  who  was  cutting  her  lateral 
incisor  teeth,  was  suddenly  seized  with  vomiting,  diarrhcea,  and  high  fever  ;  then  a  series  of 
convulsions  came  on  which  lasted  eight  hours,  the  right  side  working  most ;  at  the  end  of 
this  time  it  was  noticed  she  had  completely  lost  the  use  of  the  right  arm  and  leg,  and  the 
face  was  drawn.  Her  speech  was  affected,  so  that  she  could  not  say  any  of  the  words 
she  had  learnt.  For  more  than  a  month  she  lay  quite  helpless.  Seven  months  afterwai'ds, 
when  twenty  months  old,  she  could  not  walk  or  rest  her  weight  on  the  right  leg  ;  the  arm 
was  bent  at  the  elbow,  the  hand  clenched,  but  the  facial  paralysis  had  disappeared  ;  she 
could  say  a  few  words,  but  was  backward  in  intelligence.  At  the  age  of  four  years  she 
had  much  improved  :  she  could  walk  quite  well,  having  apparently  regained  power  in  her 
leg,  though  there  was  slight  equino-varus,  but  the  right  arm  remained  stiff  and  weak,  the 
elbow  flexed,  the  wrist  bent  and  pronated,  and  the  fingers  clenched.  The  fingers  closed 
spasmodically,  so  that  she  was  in  the  habit  of  placing  things  with  her  left  hand  between 
the  fingers  of  her  right,  where  they  were  held  without  effort.  She  could  talk  and  was  very 
intelligent. 

These  cases  may  be  taken  as  types  of  acute  cerebral  paralysis  due  to 
cerebral  haemorrhage  ;  the  symptoms  in  such  may  be  varied,  but  they  all 
three  agree  in  that  convulsions  were  present  and  the  paralysis  set  in  sud- 
denly and  unexpectedly,  as  a  surprise  to  the  attendants.  In  the  second  and 
third  there  was  high  fever. 

For  the  succeeding  few  weeks,  if  the  patient  survives,  he  remains  helpless, 
though  the  condition  gradually  improves  ;  if  there  is  antesthesia,  this  passes 
away  ;  the  aphasia,  if  present,  disappears  ;  the  face  improves,  and  still  later 
more  or  less  power  returns  in  the  muscles  of  the  legs.  The  arm  remains  in 
part  permanently  paralysed,  and  in  the  course  of  some  months  contractures 
come  on  ;  the  greatest  improvement  takes  place  in  the  muscles  about  the 
shoulder  ;  the  elbow  is  flexed,  the  wrist  flexed  and  in  a  position  of  pronation, 
the  fingers  are  bent  up,  inclosing  the  thumb.  The  amount  of  paresis  and 
contracture  varies  considerably,  according  to  the  severity  of  the  case. 
Peculiar  movements  often  occur  in  the  paralysed  limbs,  more  especially  in 
the  hands,  a  condition  to  which  the  term  '  athetosis '  has  been  applied.  The 
movements  as  a  rule  are  quite  unlike  chorea  ;  they  are  slow,  consisting  in  alter- 
nate contraction  of  opposing  muscles,  giving  rise  to  irregular  movements  of 
the  fingers  and  hand  ;  they  are  involuntary,  and  take  place  in  muscles  in 
which  there  is  ordinarily  a  certain  amount  of  tonic  spasm.  The  term'  mobile 
spasm '  has  been  applied  to  this  condition  by  Cowers.  As  the  latter  author 
points  out,  the  interossei  and  lumbricales  muscles  (which  flex  the  metacarpo- 
phalangeal and  extend  the  phalangeal  joints)  are  mostly  affected  ;  less  often 
the  long  extensor,  and  never  the  long  flexor  of  the  fingers. 

In  consequence,  the  hand  is  apt  to  assume  the  interosseal  position.  The 
movements  may  take  place  independently  in  the  interossei,  so  that  one  or 
more  fingers  may  be  extended  at  a  time,  or  all  the  fingers  may  be  extended 


Cerebral  HcemorrJias^e 


509 


and  separated,  and  the  slow  irregular  mo\-ements  of  the  extended  fingers 
suggest  the  movements  of  the  tentacles  of  a  cuttle-fish  (Gowers).  The 
movements  are  involuntary,  but  are  made  worse  by  attempts  at  voluntary 
movements. 

The  paralysed  arm  is  apt  to  grow  more  slowly  than  its  fellow,  so  that  it  is 
shorter  and  smaller,  and  often  blue  and  cold.  The  leg,  following  the  usual 
course  in  hemiplegias,  recovers  more  quickly  and  perfectly  than  the  arm  ; 
there  is  more  or  less  eciuino-varus,  and  there  may  be  some  shortening, 
but  the  child  can  get  about  fairly 
well. 

The  intelligence  often  remains 
impaired ;  sometimes  there  is 
complete  idiocy,  more  often  only 
impaired  mental  powers  or  back- 
wardness. Epilepsy  is  also 
common. 

Morbid  Anatomy. — If  an  op- 
portunity occur  of  examining  the 
brain  shortly  after  the  occurrence 
of  the  hasmorrhage,  blood  varying 
in  amount  from  a  punctiform 
haemorrhage  to  a  large  clot  or 
clots  will  be  found  beneath  the 
pia,  situated  most  commonly  at 
the  vertex,  but  also  at  times  at 
the  base  ;  it  is  usually  double, 
but  mostly  more  extensive  on 
one  side  than  the  other.  Blood 
clots  may  also  be  found  in  the 
central  white  matter,  or  in  or 
about  the  masses  of  grey  sub- 
stance at  the  base.  There  may 
be  actual  destruction  of  brain 
substance  as  a  result  of  the 
bleeding,  and  probably  in  most 
cases  softening  follows. 

If  death  occurs  after  some  years,  atrophic  changes  of  varying  amount  will 
be  found,  or  there  may  be  old  blood  cysts,  if  the  bleeding  took  place  into  the 
brain  tissue.  In  cases  in  which  there  has  been  a  hemiplegia  or  diplegia, 
the  atrophic  changes  are  situated  in  the  motor  area.  The  dura  mater  maybe 
adherent  and  the  pia  mater  thickened  over  this  area,  and  instead  of  fully 
developed  convolutions  in  the  ascending  frontal  and  parietal  regions  a 
scarring  or  cicatrisation  has  taken  place,  no  doubt  as  a  result  of  the  softening 
taking  place  after  the  htemorrhage.  This  was  the  case  in  the  brain  of  a  boy 
recently  under  the  care  of  our  colleague  Dr.  H.  R.  Hutton  (see  fig.  108),  and 
also  in  a  case  recently  shown  by  Dr.  T.  R.  Railton  at  the  Manchester  Patho- 
logical Society.^ 

In  Dr.  Mutton's  case  the  skull  was  thickened  and  flattened  over  both 
'  See  Medical  Chro/iiclt,  March  1892,  p.  429. 


Fig.  108.  — Erain  of  a  boy  aged  i8  months,  showing, 
A,  depression  over  both  motor  areas,  due  to  menin- 
geal hemorrhage  at  birth  ;  B,  cerebellum  only  par- 
tially covered  by  the  occipital  lobes.  The  patient 
had  a  typical  diplegia-     (Dr.  H.  R.  Mutton's  case.) 


5 1  o  Diseases  of  the  Nervous  System 

parietal  regions,  there  was  spastic  diplegia,  the  infant  was  an  idiot.  At  the 
post-niortcni  the  dura  mater  was  found  to  be  adherent  to  the  skull,  the  pia 
thickened  over  the  motor  area  and  adherent,  a  well-marked  depression  or 
sulcus  being  present  over  both  motor  areas.  In  some  cases  atrophy  of  the 
frontal  or  occipital  lobes  has  been  found  as  a  result  of  the  old  haemorrhage. 

Treatment. — In  connection  with  the  treatment  of  post-part  urn  cerebral 
haemorrhage,  the  most  important  matter  is  to  prevent  its  occurrence  by  so 
expediting  labour  that  the  infant  does  not  suffer  from  asphyxia.  Much  may 
be  clone  to  prevent,  very  little  can  be  done  to  cure.  We  are  powerless — as 
far,  at  any  rate,  as  drugs  are  concerned — to  remove  a  cerebral  clot  or  undo  a 
brain  damage.  Hence  the  question  of  immediate  trephining  to  remove  the 
blood  deserves  consideration,  and  will  possibly  be  in  the  future  a  recognised 
mode  of  treatment  in  cases  where  the  haemorrhage  is  local  and  superficial. 
In  those  cases  in  which  the  bleeding  is  secondary  to  convulsions,  the  most 
important  matter  is  to  prevent  any  further  return  of  the  convulsions  ;  to  this 
end  the  bromides  and  chloral  must  be  used  with  a  very  free  hand,  and  pushed 
so  as  to  render  the  infant  drowsy.  Ice  should  be  applied  to  the  head,  and 
the  head  and  shoulders  kept  well  raised.  A  moderate  purge  should  be  given, 
sufficiently  large  to  act  freely  on  the  bowels  ;  a  piece  of  mustard  leaf  may  be 
applied  to  the  back  of  the  neck  if  the  child  is  unconscious,  care  being  taken 
not  to  leave  it  on  long  enough  to  produce  a  sore.  The  drugs  most  likely  to 
be  of  service  are  small  doses  of  digitalis,  to  steady  and  increase  the  power  of 
the  heart,  and  bromide  in  full  doses  if  there  is  any  tendency  to  convulsions. 
The  paralysed  limbs  should  be  wrapped  in  cotton  wool.  As  the  patient  is 
recovering  from  the  effects  of  the  attacks,  nux  vomica,  iron,  and  syrup  of  the 
hypophosphites  may  be  given.  In  the  later  stages,  when  contractures  are 
setting  in,  massage  should  be  diligently  and  intelligently  employed  ;  but  the 
patient's  friends  must  be  warned  that  a  cure  is  not  likely  to  be  effected  by 
any  form  of  treatment,  and  that  rubbing,  as  also  galvanism,  is  only  palliative. 
Every  effort  should  be  made  to  bring  out  the  patient's  voluntary  power.  The 
deformities  resulting  may  be  improved  by  division  of  tendons  and  the  appli- 
cation of  splints.^ 

With  regard  to  prognosis,  it  is  well  to  give  a  carefully  guarded  opinion 
as  to  the  future.  Nearly  all  cases  improve,  and  slight  paralyses  get  quite 
well.  Severe  cases  improve  as  years  go  on,  but  it  is  doubtful  if  they  ever 
completely  recover.  In  the  majority  of  cases  there  is  some  mental  feeble- 
ness, either  a  mere  backAvardness,  or  there  may  be  decided  idiocy.  Some 
cases  become  epileptic. 

3taedullary  Haemorrhagre.— In  speaking  of  hemophilia  and  of  the 
haemorrhagic  diathesis  we  have  mentioned  the  fact  that  a  cerebral  hemor- 
rhage may  occur  in  these  conditions  after  a  slight  head  injury.  We  have 
related  such  a  case  (p.  443),  and  referred  to  some  cases  related  by  Steffen. 
The  following  case  is  a  rare  one  belonging  to  the  same  category  : 

Hmnophilia  ;  Medullary  Hcemorrtiage. — Norah  M. ,  aged  3  years  10  months.  Family 
history  good.  Father  two  years  before  suddenly  lost  the  hearing  in  one  ear,  which  was 
supposed  to  be  due  to  haemorrhage.  Patient  had  a  sharp  attack  of  scarlet  fever,  followed 
by  glandular  abcesses  eighteen  months  ago.     For  the  last  year  it  had  been  noticed  that 

1    Vide  Willard,  Trans.  American  Orthop.  Assoc.  September  1891. 


Meduhary  Hccmorrhage 


1 1 


she  had  exhibited  a  tendency  to  '  bruise,'  purple  spots  appearing  on  the  skin  after  the 
shghtest  injuries.  She  was  a  well-nourished  child,  but  had  always  been  difficult  to  feed. 
She  was  quite  well  till  the  morning  of  December  22,  when  she  vomited  and  retched  several 
times  ;  there  was  no  history  of  a  blow,  but  she  had  been  to  a  children's  party  the  evening 
before  and  had  romped  a  good  deal.  The  following  day  she  was  seen  with  Dr.  Lawton  ; 
was  then  noted  she  could  not  stand  or  sit,  and  when  held  up  her  head  fell  to  the  right  side. 
There  was  slight  paralysis  of  the  left  side  of  the  face,  including  the  orbicularis,  but  the  eye 
could  be  closed  ;  the  voice  was  weak  and  had  a  nasal  twang  ;  on  attempting  to  swallow, 
she  coughed  and  spluttered  as  if  some  of  the  fluid  entered  the  larynx.  There  was  no 
cardiac  murmur.  Temperature  98°.  December  2^. — She  had  recovered  some  power  in 
her  legs,  and  she  could  sit  up,  but  her  head  still  fell  over  to  the  right  side.  It  was  noticed 
that  her  breathing  was  peculiar,  the  right  side  of  the  chest  was  moving  excessively,  while 
the  left  side  was  hardly  moving  at  all  ;  rS,les  were  heard  on  both  sides.  December  25. — 
The  swallowing  was  better,  but  it  was  clear  the  lungs  were  getting  choked,  as  the  rales  were 
heard  freely  all  over,  the  right  side  still  moving  more  freely  than  left.     Temperature  102°. 

The  child  became  more  and  more  dusky,  the 
respirations  increasing  in  number  ;  there  was 
intense  restlessness,  and  finally  death  from 
asphyxia  on  the  evening  of  December  26. 
Post-mortem  (head  onl}'). — No  cerebral  hee- 
morrhage  except    in    the   medulla,  where   it 


Fig.  109. — PostLi  ior  aspect  of  medulla  showin 
discoldration  over  clot  (nat.  size). 


Fig.  lie. -Transverse  section  of  medulla 
through  middle  of  olivary  body  showing 
laminated  clot,  compressing  the  right 
olivarj'  nucleus,  root  of  vagus,  and  nerve 
centres  in  floor  of  fourth  ventricle. 
v,  vagus.     H,  hypoglossal  (nat.  size). 


was  noted  that  the  right  side  of  the  medulla 
was  swollen  and  discoloured  (see  fig.  109).  On 
transverse  section  (after  hardening)  through 
the  middle  of  the  olivary  bodies,  a  round  lami- 
nated clot  h  inch  in  diameter  was  found,  which 
had  compressed  the  root  of  the  right  vagus, 
olivary  nucleus,  and  also  the  nuclei  in  the 

lower  part  of  the  floor  of  the  fourth  ventricle  (see  fig.  no).      We  are  indebted  to  Dr. 

R.  T.  Williamson  for  microscopical  examination  of  the  clot.     He  found  no  evidence  of 

any  aneurismal  sac. 

Embolism. — Among  the  various  causes  producing  a  paralysis  of  hemi- 
plegic  distribution  we  must  mention  embolism.  Embolism  chiefly  occurs  in 
patients  suffering  from  endocarditis,  but  also  it  appears  to  occur  at  times 
when  there  is  no  form  of  heart  disease  present,  the  thrombus  appearing  to  form 
in  the  left  auricle,  or  pulmonary  veins.  Embolism  is  perhaps  most  common 
m  acute  or  malignant  endocarditis  ;  this  was  so  in  the  case  recorded  on 
page  409  (see  fig.  iii). 

In  the  following  case  there  was  hemiplegia  in  consequence  of  a  blocking 
of  the  middle  cerebral  artery,  either  from  embolism  or  thrombosis  : 

A  boy  of  one  year  old,  who  had  suffered  since  birth  from  marked  cyanosis  due  to 
obstructive  pulmonary  disease  (fig.  76  represents  the   heart  of  this  case)  and   constant 


512 


Diseases  of  the  Nervous  System 


dyspepsia,  was  seized  one  night  with  vomiting  and  convulsions,  followed  by  paralysis  of 
the  left  arm  and  leg.  When  seen  on  the  following  morning,  the  head  and  neck  were 
turned  to  the  right  side,  the  eyes  were  suffused  and  blinking,  as  if  some  foreign  body  was 
present,  the  right  pupil  was  smaller  than  the  left,  but  both  acted  to  light ;  the  child  was 
apparently  quite  blind  ;  there  were  no  retinal  haemorrhages,  and  the  optic  discs  were 
normal.  The  face  was  drawn  to  the  right  side  ;  there  was  complete  loss  of  power,  and 
apparently  loss  of  sensation,  in  both  arm  and  leg  of  the  left  side  ;  no  cry  could  be  elicited 
on  pinching  or  pricking  the  skin  of  either  limb.  The  child  was  drowsy,  but  not  uncon- 
scious, as  he  appeared  at  times  to  know  his  mother  when  in  her  lap.  He  was 
apparently  deaf  for  the  first  twenty-four  hours,  though  there  was  necessarily  some  diffi- 
culty in  ascertaining  this  ;  by  the  next  day,  though  remaining  blind,  he  knew  the  voices 
of  his  friends,  and  turned  towards  the  direction  of  their  voices  ;  it  was  clear,  also,  that  he 
heard  with  both  ears.     Within  a  fortnight  sight  had  returned,  so  that  he  could  recognise 


Fig.  III.  — Horizontal  Sectior  showing  patch  of  softening  involving  the  left  lenticular 

nucleus  and  anterior  limb  &i  m^  mLv-mal  capsule.     The  lenticular-striate  artery  was  plugged 
with  an  embolus_and  impervious.  There  was  complete  hemiplegia  of  the  right  side.  (See  p.  /log.) 


his  mother  and  his  t03^s.  His  friends  thought  he  regained  his  sight  first  in  his  right  eye. 
By  the  end  of  six  weeks  sensation  had  returned,  as  far  as  could  be  judged,  in  the  arm  and 
leg,  and  some  power  was  returning,  as  he  moved  both  limbs  on  the  left  side.  A  week  or 
two  later  he  could  hold  a  rattle  in  the  left  hand,  but  not  raise  it  to  his  mouth;  the  leg 
showed  a  tendency  to  draw  up,  and  the  knee  refle.x  was  much  exaggerated.  The  child 
was  quite  intelligent  and  bright.  Before  death  (seven  months  after  seizure)  much  improve- 
ment had  taken  place  ;  the  child  could  put  out  his  hand,  but  there  was  some  rigidity  both 
in  the  arm  and  leg.  Death  occurred  from  bronchitis.  Post-mortem. — On  removing  the 
brain,  it  was  evident  the  right  hemisphere  had  shrunk,  being  slightly  smaller  than  the  left, 
and  that  there  was  a  large  cyst  (porencephalus),  containing  clear  fluid,  occupying  the 
central  part  of  the  convexity  of  the  right  hemisphere  (see  fig.  112) ;  the  cyst  corresponded 
with  the  distribution  of  the  middle  cerebral  artery,  excepting  the  branch  to  the  inferior 
frontal  convolution.     The  middle  cerebral  artery  beyond  its  first  branch  was  impervious, 


Embolism  of  the  Brain 


513 


and  contained  old  clot.  It  was  quite  clear  in  this  case  that  there  had  been  thrombosis  or 
embolism  of  the  middle  cerebral,  with  a  subsequent  softening  of  the  area  supplied  by  it ; 
a  horizontal  section  showed  that  the  internal  capsule  had  been  compressed. 

No  emboli  were  found  elsewhere  ;  there  was  no  endocarditis  of  the  mitral 
or  aortic  valves,  but  a  much-contracted  pulmonary  artery  and  open  foramen 
ovale. 

Dr.  F.  Taylor  records  a  typical  case  of  embolism  following  endocarditis  : 

A  boy  of  five  years,  two  weeks  after  an  attack  of  scarlet  fever,  was  seized  with  hemi- 
plegia of  the  right  side  ;  the  urine  was  albuminous.  Death  occurred  froni  diphtheria 
nine  weeks  afterwards  ;  embolism  of  the  left  middle  cerebral  artery,  with  extensive  soften- 
ing of  the  left  hemisphere,  was  found.     Tliere  was  endocarditis  of  the  mitral  valve. 

Abercrombie  reports  a  case  of  a  boy  aged  six  years  who  was  under  treat- 
ment for  diphtheria,  and  who  on  the  fifteenth  day  was  seized  with  general 
con\ulsions  and  left  hemiplegia  ;  he  died  eleven  days  later.     The   middle 


Fig.  112. — Cyst  formed  by  softening  of  brain  substance,  secondary  to  obstruction  of  the  middle 
cerebral  artery  bej'ond  the  first  branch  (to  inferior  frontal  convolution).  The  cyst  wall  has 
fallen  in  from  escape  of  its  contents.  Child  nineteen  months  old  ;  death  seven  months  after 
onset  of  paralysis. 

cerebral  ariery  was  found  plugged  with  an  embolus  ;  infarcts  were  also  found 
in  the  spleen  and  kidneys.  There  was  no  heart  disease,  and  it  was  difficult 
to  understand  the  source  of  the  emboli,  unless  formed  in  the  cavity  of 
the  heart  or  in  the  pulmonary  veins  ;  this  might  be  possible  in  paresis  of  the 
respiratory  muscles  and  disturbed  innervation  of  the  heart,  following 
diphtheria.  Dr.  Trevelyan  reports  a  similar  case  to  Dr.  F.  Taylor's,  in  a 
girl  aged  eight  years  convalescent  from  diphtheria. 

A  sudden  hemiplegia  may  be  caused  by  meningitis,  the  immediate  cause 
being  softening  following  thrombosis  or  embolism  of  the  vessels  ;  the 
meningitis  is  usually  tubercular.  Thus  a  boy  of  six  months  of  age,  who  had 
been  apparently  healthy,  suffered  for  a  week  or  two  from  febrile  disturbance, 
dyspepsia,  and  irritability,  attributed  not  unnaturally  by  his  friends  to 
'  teething  : '  one  evening  at  8  P.M.  he  was  convulsed,  the  right  arm  and  leg 
twitching  most  :  this  was  followed  by  right  hemiplegia,  including  the  face. 
At  3  A.M.,  when  seen,  the  infant  was  unconscious,  with  contracted  pupils, 
Cheyne-Stokes  respiration,  the  face  drawn  to  the  left,  the  right  arm  and  leg 

L  L 


5.14  Diseases  of  the  Nervous  System 

completely  powerless.  Death  took  place  three  days  later,  the  temperature 
rising  in  the  meantime  to  105°.  T]\e  post-7nortem  showed  a  basal  meningitis 
(tubercular),  much  fluid  in  the  lateral  ventricles,  and  softening  of  the  left 
hemisphere  and  corpus  striatum. 

Another  lesion  (this  a  rare  one)  giving  rise  to  hemiplegia  is  an  aneurism 
of  the  middle  cerebral  artery,  the  result  of  embolism  in  cases  of  acute 
endocarditis  ;  this  was  the  case  in  a  girl  of  nine  years  under  our  care  who 
suffered  from  intermittent  pyrexia  and  albuminuria,  and  in  whom  a  loud 
systohc  murmur  was  present.  To  these  symptoms  was  added  acute  pain  in 
the  frontal  region,  coming  on  suddenly.  An  ophthalmoscopic  examination 
showed  large  retinal  hccmorrhages  surrounding  the  disc.  A  week  later  there 
was  paresis  of  the  right  arm,  no  paralysis,  but  exaggerated  tendon  reflex  of 
the  right  leg.  Six  weeks  later  she  fell  back  unconscious  while  sitting  up  in 
bed  :  there  was  now  right  facial  paralysis,  and  paralysis  of  the  right  leg. 
Death  followed  ten  days  later.  An  aneurism  the  size  of  a  small  walnut, 
on  the  second  branch  (to  the  ascending  frontal  convolution),  near  its  origin 
from  the  trunk  of  the  left  middle  cerebral  artery,  which  had  ruptured  and 
given  rise  to  meningeal  hsemorrhage,  was  found  ^cj-/  mortem. 

Throraatoosis  of  the  CJerelJral  Sinuses  amd  Veins. — Thrombosis  of  the 
cerebral  sinuses  or  veins  is  not  a  common  occurrence  during  infancy  and 
childhood.  It  may  occur  in  the  superior  longitudinal,  lateral,  or  cavernous 
sinus.  It  is  most  likely  to  occur  in  extreme  anremia,  after  exhausting 
diseases  as  acute  diarrhoea,  where  the  force  of  the  heart  is  weakened  and  a 
stasis  or  slowing  of  the  venous  current  takes  place.  Thrombosis  may  also 
occur  in  the  surface  veins  under  similar  circumstances,  or  the  clotting  in  the 
veins  may  be  the  result  of  meningitis.  The  immediate  result  of  the  obstruc- 
tion to  the  veins  or  sinuses  is  to  distend  the  venous  branches  behind  the 
obstruction  to  their  utmost  capacity,  and  possibly  also  to  give  rise  to  puncti- 
form  haemorrhage  and  softening  of  the  brain.  Thrombosis  of  venous 
channels  may  take  place  in  the  neighbourhood  of  some  inflammation,  as  in 
otitis,  and  pyaemia  may  result. 

Symptoms. — There  is  a  condition  of  great  exhaustion  and  pallor,  and  to 
these  are  added  cerebral  symptoms  and  venous  obstruction.  The  fontanelle 
is  tense,  the  veins  of  the  forehead,  nose,  and  face  are  distended  ;  there  is 
epistaxis  and  probably  convulsions  ;  perhaps,  also,  rigidity  and  retraction  of 
the  neck,  and  paralysis  of  one  or  more  extremities.  In  making  a  diagnosis, 
it  must  be  remembered  that  the  so-called  '  false-hydrocephaloid '  or  cerebral 
aneemia  gives  rise  to  convulsions,  stupor,  and  coma,  and  is  infinitely  more 
common  than  thrombosis.  We  are  only  justified  in  diagnosing  the  latter 
when  there  is  distension  of  the  veins  of  the  face  and  forehead,  or  some 
definite  paralysis.  Thrombosis  of  the  cavernous  sinus  is  most  likely  to  occur 
in  some  local  lesion,  as  a  tumour,  as  a  periosteal  sarcoma  of  the  sphenoid 
bone,  or  caries  ;  the  eyeball  is  prominent,  there  is  oedema  of  the  eyelids  and 
distension  of  the  veins  of  the  forehead. 

Treatment. — The  action  of  the  heart  must  be  strengthened  by  stimulants 
and  digitalis,  and  the  tendency  to  exhaustion  and  syncope  must  be  combated 
by  beef  tea  and  highly  concentrated  forms  of  nourishment.  The  patient 
should  be  kept  in  the  prone  position  as  much  as  possible,  with  the  shoulders 
and  head  raised.     The  prognosis  is  necessarily  extremely  grave. 


515 


CHAPTER   XXIV 

DISEASES   OF  THE  NERVOUS   ?,Y5T'EU—CO)lti7tued 

Chorea 

Chorea  is  a  disease  which  occurs  chiefly  in  children  between  the  ages  of 
six  and  fifteen  years,  and  is  characterised  by  irregular  spasms  of  the  volun- 
tary muscles,  and  in  some  cases  by  paresis  of  the  extremities  and  mental 
weakness. 

^-Etiology. — Chorea  can  hardly  be  said  to  be  hereditary,  but  undoubtedly 
a  tendency  to  neuroses  or  '  weak  nerves '  runs  in  families,  and  instances 
might  be  adduced  of  emotional  parents  having  children  who  suffer  from 
chorea  ;  moreover,  it  is  a  common  experience  to  find  several  sisters  or  brothers 
suffering  from  chorea,  or  perhaps  one  or  more  are  neurotic  or  hysterical. 

Chorea  is  not  common  before  the  age  of  six  years,  and  after  the  age  of 
fifteen  years  the  liability  to  attacks  becomes  very  much  less.  It  is  more 
common  in  girls  than  boys,  in  this  respect  resembling  hysteria  and  other 
emotional  diseases.  Analysing  633  cases  which  have  attended  at  the  Chil- 
dren's Hospital,  we  find  that  454  were  girls  and  179  were  boys,  giving  a 
proportion  of  five  girls  to  two  boys  ;  these  figures  closely  correspond  to  the 
statistics  collected  by  other  writers.^  In  252  cases  the  ages  of  the  patients 
Avere  analysed,  giving  the  following  result  : 

Under  six  years    .         .         .         .  15=    3  boys  and  12  girls 

Between  six  and  ten  years    .         .         102  ==  35  boys  and  67  girls 
Between  ten  and  fifteen  years       .         135  =44  boys  and  91  girls 

The  youngest  child  was  a  girl  of  four  years  of  age. 

The  children  most  apt  to  suffer  are  the  nervous  and  excitable,  those  who 
are  easily  frightened,  especially  if  they  are  suffering  from  ill-health,  the  result 
of  unfavourable  life-conditions  or  rapid  growth. 

By  far  the  commonest  exciting  cause  is  a  fright  ;  in  38  cases  out  of  252 
there  was  a  definite  history  of  the  patient  being  frightened,  the  symptoms 
following  in  some  cases  next  day,  in  others  within  a  few  days  or  a  week. 
The  causes  of  the  fright  were  various  :  in  one  case,  that  of  a  boy,  the  symptoms 
followed  three  days  after  seeing  a  '  man  with  his  throat  cut ; '  sometimes  the 
attack  was  ascribed  to  a  '  dog  having  flown  at  the  child,'  or  the  patient 
was  '  frightened  by  a  policeman,'  or  the  child  had  been  caned  by  the  school- 
mistress or  had  had  a  fall  downstairs.  In  such  histories  there  is  often  some- 
thing it  is  necessary  to  discount  :  probably  the  scoldings  at  school  were  the 

1  See  Fagge's  PriticiJ>les  and  Practice  of  Medicine,  edited  by  Pye-Smith,     2nd  edit. 

L  L  2 


5i6  Diseases  of  the  Nervous  System 

consequence  and  not  the  cause  of  the  chorea  ;  but,  on  the  other  hand,  it  is 
certain  that  chorea  may  follow  within  a  few  hours  of  a  serious  shock  to  the 
nervous  system. 

Mental  strain,  as  working  hard  for  an  examination,  in  some  cases  appears 
to  excite  an  attack  ;  this  has  occurred  too  often  in  our  experience  to  be 
attributed  to  any  mere  coincidence.  Given  a  fast-growing  and  delicate  girl 
of  excitable  disposition  and  not  too  well  fed,  who  is  at  school  for  many  hours 
during  the  day,  and  has  to  divide  her  attention  between  home  lessons  and 
various  domestic  duties,  so  that  she  becomes  little  else  than  a  drudge,  we 
can  hardly  be  surprised  if  she  suffers  from  a  nervous  breakdown.  '  School- 
made  chorea,'  as  Dr.  Sturges  calls  it,  is  not  by  any  means  confined  to  the 
poorer  classes,  and,  although  among  the  better-to-do  classes  there  is  no 
question  of  poor  food  and  household  drudgery,  yet  there  is  often  much 
forcing  exercised  to  induce  a  girl,  of  perhaps  delicate  health,  to  keep  pace 
with,  or  run  ahead  of,  her  stronger  and  more  robust  class-mates. 

In  some  instances  children  who  are  convalescent  from  various  depressing 
diseases,  such  as  acute  rheumatism,  enteiic  fever,  or  scarlet  fever,  are  attacked 
with  chorea.  Rheumatism  excepted,  enteric  fever  in  our  experience  more 
often  than  any  other  disease  predisposes  to  chorea  ;  other  nervous  dis- 
orders, such  as  dementia,  mania,  and  aphasia,  are  not  uncommon  after 
enteric, 'and  are  no  doubt  due,  as  is  also  the  chorea,  to  the  anaemia  and 
exhaustion  caused  by  the  long  drain  on  the  system  during  the  disease.  For 
the  connection  of  rheumatism  with  chorea,  see  p.  519. 

Heart  disease  in  some  instances  precedes  the  attack  of  chorea,  or,  in  other 
words,  chorea  makes  its  appearance  in  children  suffering  from  cardiac  disease. 

It  sometimes  happens  that  a  source  of  irritation  in  some  part  of  the  body 
is  the  exciting"  cause  of  an  attack  of  chorea  ;  thus  we  have  seen  a  temporarj^ 
chorea  occasioned  by  suppuration  in  the  middle  ear,  the  choreic  movements 
ceasing  when  the  discharge  made  its  appearance.  In  other  cases  it  happens 
that  chorea  is  an  early  symptom  in  pericarditis — this  we  have  also  seen  ;  in 
one  case,  in  a  little  girl  of  four  years,  choreic  movements  preceded  by  a  few 
days  the  physical  signs  of  a  pericarditis  which  proved  fatal.  We  cannot 
help  thinking  that  in  such  a  case  the  chorea  was  symptomatic  of  the  pericar- 
ditis, the  latter  being  the  primary  lesion,  rather  than  that  the  heart  lesion  was 
secondary  to  the  chorea. 

Imitation  in  some  cases  seems  to  be  a  factor  in  the  production  of  chorea. 
On  one  occasion  five  cases  occurred  in  a  girls'  school  immediately  after  the 
admission  of  a  child  suffering  from  chorea  ;  in  such  cases,  perhaps,  it  may 
not  be  imitation  so  much  as  fright  at  seeing  others  affected,  as  Gowers 
suggests.  We  have  never  known  children  in  the  same  ward  to  become 
choreic  in  consequence  of  a  bad  case  being  admitted,  but  we  have  seen 
cases  of  chorea  apparently  made  worse  by  association  with  a  bad  case. 

Symptoms. — Most  of  those  who  suffer  from  chorea  are  in  some  way  or 
other  weakly,  or  at  least  not  in  robust  health  ;  they  are  often  anaemic,  rapidly 
growing  girls.  Not  infrequently,  it  occurs  in  girls  who  have  gone  out  to 
service,  and  who  are  undertaking  work  which  is  beyond  their  strength.  Often 
the  first  symptoms  are  a  loss  of  control  over  the  muscles,  especially  the 
flexors  and  extensors  of  the  fingers  and  wrists,  and  a  want  of  precision  in 
the  movements  of  the  hands.    The  patient  drops  cups  and  saucers  on  the  floor, 


Chorea  517 

is  unable  to  do  needlework,  fumbles  sadly  when  she  attempts  to  tie  a  piece 
of  string,  or  spills  her  food  when  she  passes  it  to  her  mouth.  Sometimes, 
especially  in  }  ounger  children,  the  first  thing  noticed  is  that  she  '  makes 
faces,'  her  mouth  screwing  up  so  as  to  make  grotesque  grimaces,  while  she 
fidgets  with  her  fingers,  and  when  she  attempts  to  dress  herself  makes  use- 
less, clumsy,  ineffectual  movements.  All  this  may  go  on  for  many  days, 
perhaps  weeks,  without  the  friends  thinking  the  child  is  really  ill,  and  perhaps 
she  gets  scolded,  both  at  home  and  at  school,  for  her  clumsy  ways  and 
inattention  to  her  work.  It  is  needless  to  say  the  scoldings  do  no  good.  Sooner 
or  later  the  movements  become  too  obvious  to  escape  attention  ;  indeed,  it 
is  apparent  to  everyone  that  something  is  wrong.  These  movements,  as 
Dr.  Sturges  points  out,  are  much  more  vigorous  in  the  upper  part  of  the  body 
than  the  lower,  the  hands  suffering  most  of  all.  The  fingers  are  opened  and 
shut,  the  extensor  and  flexor  muscles  being  constantly  worked  ;  the  arm  is 
passed  behind  the  back,  then  brought  to  the  front  ;  if  asked  to  shake  hands, 
it  is  thrust  rapidly  forward,  being  directed  with  difficulty  to  the  hand  to  be 
grasped.  The  tongue  is  protruded  with  a  jerk,  and  perhaps  drawn  back 
again  in  a  moment  with  a  quick  movement.  The  muscles  of  the  face  are 
frequently  spasmodically  contracted,  so  that  the  queer  grinning  grimaces  are 
constantly  being  made.  The  muscles  of  the  neck  are  frequently  contracted 
and  relaxed,  so  that  the  head  is  moved  from  side  to  side  or  rotated.  When 
the  child  walks,  the  feet  join  in  the  spasmodic  movements,  so  that  the  gait 
is  altered,  the  legs  being  thrown  forward  quickly,  or  if  the  patient  stands  the 
feet  are  restless,  being  shifted  about  from  place  to  place.  When  the  patient 
is  at  rest  in  bed  she  will  lie  still  if  nor  disturbed,  but  directly  she  is  interfered 
with — as,  for  instance,  to  examine  the  chest — the  movements  begin,  the  hands, 
face,  and  trunk  muscles  being  thrown  into  a  state  of  clonic  spasm.  The 
muscles  of  respiration  do  not  escape  :  the  child  takes  a  deep  sighing  inspira- 
tion, then  perhaps  there  is  a  series  of  shallow  irregular  respirations.  The 
irregular  respirations  may  affect  the  pulse,  so  that  it  is  irregular  and  inter- 
mittent. The  movements  cease  during  sleep,  though  sleep  is  not  readily 
obtained  ;  indeed,  in  the  worst  cases  the  patient  only  sleeps  when  under  the 
influence. of  chloral  or  opium,  which  has  to  be  freely  given  in  order  to  secure 
rest.  In  the  milder  cases  the  movement  may  be  confined  to  one  side  ;  this, 
however,  is  never  the  case  when  the  movements  are  severe,  though  it  is  very 
common  to  have  the  clonic  spasms  more  vigorous  on  one  side  than  the  other. 
A  bemlcborea,  in  which  the  movements  are  vigorous  and  entirely  confined 
to  one  arm  or  leg,  is  probably  due  to  some  organic  cerebral  disease. 

The  temperature  is  usually  normal  throughout,  sometimes  subnormal  ; 
if  there  is  any  fever,  peri-endocarditis  or  rheumatism  should  be  suspected. 
In  the  most  severe  cases  the  temperature  may  be  raised  a  degree  or  two. 

There  is  often  marked  paresis  of  an  arm  or  leg,  far  more  commonly  the 
former  ;  not  only  is  the  grasp  feeble,  but  the  arm  is  weak  and  powerless, 
though  complete,  or  indeed  well-marked,  paralysis  does  not  occur.  This 
paresis  of  an  arm  is  sometimes  the  most  prominent  feature  in  the  case,  but 
in  all  cases  more  or  less  of  clonic  spasm  may  be  detected  in  the  fingers  or  in 
the  facial  muscles.     These  cases  have  been  spoken  of  as  '  paralytic  chorea.' 

The  electric  irriiability  of  the  muscles  in  cases  of  hemichorea  has  been 
studied  by  several  observers,  most  recently  by  Gowers,  cases  of  hemichorea 


5  1 8  Diseases  of  the  Nervous  System 

being  selected  on  account  of  the  possibility  of  comparing  the  muscles  of  one 
side  with  the  other.  In  some  cases  no  difference  can  be  detected,  but  in 
others  there  has  been  noted  an  increase  of  irritability  on  the  affected  side, 
the  muscles  contracting  with  a  weaker  faradic  and  also  voltaic  current  than 
those  on  the  unaffected  side. 

The  speech  is  affected,  in  some  cases  from  the  muscles  of  the  tongue, 
jaw,  and  larynx  not  being  under  sufficient  control.  In  other  cases  the  mental 
weakness  frequently  present  may  be  the  cause.  Headaches  are  often  com- 
plained of;  sometimes,  especially  in  cases  of  'hysterical  chorea,'  there  is 
hypercesthesia  or  anaesthesia. 

Optic  neuritis  has  been  observed  by  Gowers,  slight  in  degree  in  some 
cases  ;  in  one  case  there  was  a  sufficient  degree  to  make  it  comparable  to 
the  neuritis  seen  in  a  case  of  cerebral  tumour.  In  the  vast  majority  of  cases 
there  are  no  ophthalmoscopic  changes. 

The  mental  state  is  often  peculiar.  There  is  a  vacant,  listless  expression 
on  the  face,  in  many  cases  a  dulness  of  comprehension.  The  child  may 
cry  on  the  slightest  provocation.  Thei'e  may  be  actual  dementia,  or,  on  the 
other  hand,  maniacal  excitement. 

In  the  worst  cases  the  movements  are  severe  :  the  child  constantly 
wriggles  about,  and  the  arms  and  legs  move  sufficiently  violently  to  throw  the 
patient  out  of  bed.  The  constant  movements  of  the  limbs  chafe  the  skin  on 
the  extensor  surfaces,  so  that  unhealthy  looking  sores  may  result.  We  have 
seen  such  in  a  fatal  case  become  actually  gangrenous  before  death.  The 
patient  is  sleepless,  and  becomes  anaemic  and  completely  exhausted.  Death, 
however,  may  not  result  from  actual  exhaustion,  it  may  occur  in  consequence 
of  pyaemia  or  pericarditis.  Among  over  634  cases  there  were  five  deaths,  but 
one  of  these  died,  not  from  chorea,  but  from  an  intercurrent  tubercular 
meningitis.  All  five  cases  were  in  girls  ;  indeed,  fatal  cases  in  boys  are  very 
rare.  Dr.  Fagge  relates  the  case  of  a  boy  who  died  in  nine  days,  and  another 
boy  of  twelve  years  who  died  from  obstructed  breathing  due  to  glossitis,  the 
tongue  having  been  severely  bitten. 

The  following  is  the  history  of  a  fatal  case  of  chorea  : 

Chorea,  Endocarditis,  Death. — Maggie  May  B.,  aged  10  years.  Four  members  of 
the  same  family  have  recently  suffered  from  sore  throats  and  fever  due  to  drain  smells  at 
the  back  of  the  house.  No  history  of  rheumatism  or  previous  attack  of  chorea.  Patient 
has  been  attended  at  home  by  Dr.  V.  Brown.  She  has  had  severe  chorea  at  home  for 
two  weeks.  Admitted  February  27,  1891.  The  choreic  movements  are  moderately  severe  ; 
she  cannot  feed  herself;  the  heart's  action  is  irregular,  but  there  is  no  bruit;  there  is 
incontinence  of  urine  ;  sordes  on  her  lips  and  teeth  ;  temperature,  98°-ioo°  ;  sleeps  badly. 
March  2. — Has  been  taking  bromide  and  chloral,  is  quieter,  and  the  movements  are 
less  ;  temperature,  96°-98°.  March  9. — Still  improving,  no  bruit  heard,  sleeps  better. 
March  11. — The  temperature  has  gone  up  to  104°  F.  this  afternoon;  the  movements  are 
now  very  violent ;  chloroform  has  been  given  to  quiet  the  excessive  movements.  Bruit 
heard  for  the  first  time  at  the  apex.  Nepenthe  in  lo-minim  doses  seems  to  excite  ;  chloral 
appears  to  answer  better.  March  16. — Has  been  taking  bromide,  chloral,  and  hyoscya- 
mus  ;  is  quieter,  but  takes  food  with  difficulty  ;  temperature,  97°-ioi°.  Extensor  surfaces 
of  the  arm  are  very  rough  and  sore  from  friction  ;  there  is  swelling  of  the  right  parotid. 
March  19. — Much  worse  to-day.     Respiration,  Cheyne-Stokes.     Died  in  the  evening. 

Post-mortem. — Skin  covering  elbows  and  wrists  roughened  and  abraded,  ulcer  on  ball 
of  thumb,  ulcer  over  styloid  process  of  radius  and  lower  end  of  ulna ;  both  ears  are 
abraded  ;   hair  at  back  of  head  worn  off;    knuckles  abraded.     Much  sweUing  of  right 


Chorea  519 

parotid.  Lungs. — Old  adhesions  round  left ;  right  upper  lobe  dark  red,  solid  behind, 
and  sinks  in  water  ;  anterior  edge  emphysematous  ;  lower  lobe  semi-solid.  There  are 
patches  of  consolidation  in  the  left  lung  ;  the  back  of  the  upper  lobe  is  engorged.  Heart 
\6\  oz.)  is  firmly  contracted,  especially  left  ventricle.  Mitral  valves  show  recent  endo- 
carditis, the  edges  being  beaded  (see  fig.  79,  which  was  drawn  from  this  case) ;  other 
valves  healthy.  No  dilatation  or  hypertrophy.  Intestines  congested,  Peyer's  patches 
swollen,  slightly  abraded  in  places.  Liver  (44  oz.)  enlarged  and  congested.  Spleen 
(4i  oz. )  large  and  soft.  ICidneys  conge?AeA.  Brain. — Veins  on  surface  full.  Arachnoid 
membrane  opaque  and  cloudy,  excess  of  subarachnoid  fluid.  There  is  a  patch  of  what 
appears  to  be  lymph  on  the  convex  surface.  In  the  Sylvian  fissure  the  arachnoid  is 
especially  opaque.     The  brain  substance  is  firm,  the  capillaries  are  congested. 

Chorea  is  a  chronic  disease  lasting  for  many  weeks,  often  many  months, 
but  it  is  usually  not  ecjually  severe  throughout  this  period.  Ten  weeks  is 
often  stated  to  be  the  average  ;  it  certainly  is  often  much  longer.  Relapses 
are  exceedingly  common  ;  it  is  not  uncommon  for  children  to  have  three  to 
five  attacks,  but  the  tendency  passes  off  after  puberty. 

Complications. — In  the  majority  of  cases  of  chorea  the  heart  is  in  some 
way  or  other  affected.  In  some  cases  chorea  apparently  supervenes  in 
children  who  are  suffering  from  chronic  heart  disease  ;  in  a  few  cases  it 
appears  to  be  brought  on  by  an  attack  of  pericarditis,  but  in  the  majority  of 
cases  the  heart  complication  comes  on  during  the  course  of  an  attack  of 
chorea.  Out  of  252  cases  of  chorea,  nothing  abnormal  was  noted  in  the 
heart's  action  in  79  ;  in  54  there  was  irregularity  or  reduplication  of  the 
sounds  ;  in  119,  bruits,  mostly  heard  at  the  apex  more  loudly  than  at  the  base, 
were  detected.  Some  of  these  bruits  were,  no  doubt,  anaemic,  inasmuch  as 
they  were  present  only  at  the  base  ;  it  is  seldom,  however,  possible  to  say 
dogmatically  that  a  bruit  heard  during  the  course  of  chorea  is  simply  hcEmic, 
and  it  is  necessary  to  have  the  patient  under  observation  for  a  long  period 
during  convalescence  before  we  are  in  a  position  to  say  if  a  so-called  hsemic 
bruit  is  due  to  organic  disease  or  not.  It  is  well  also  to  remember  that 
endocarditis  may  occur  and  yet  no  bruit  be  produced  ;  thus  we  have 
sometimes  failed  to  detect  bruits  in  cases  of  chorea,  but  some  months  after- 
wards have  noticed  undoubted  organic  murmurs.  Both  mitral  and  aortic 
valves  may  be  affected,  though  the  former  are  far  more  commonly  affected 
than  the  latter  ;  while  many  of  those  in  whom  bruits  are  heard  during  chorea 
have  suffered  from  rheumatism,  this  is  by  no  means  the  case  with  all. 

i^cute  or  sub-acute  rlieumatisin  was  associated  with  chorea  in  46  out 
of  252  cases,  while  20  more,  according  to  their  friends'  account,  suffered  from 
'  rheumatic  pains.'  Statistics  with  regard  to  the  association  of  chorea  and 
rheumatism  vary  considerably,  but  this  is  hardly  surprising,  inasmuch  as  we 
are  largely  dependent  upon  the  histories  given  by  friends,  and  their  ideas 
concerning  rheumatism  are  apt  to  be  vague  ;  moreover,  the  symptoms  of 
rheumatism  are  often  less  well-marked  in  children  than  in  adults,  and 
rheumatic  attacks  may  be  easily  overlooked,  or  at  least  may  not  be  recog- 
nised as  rheumatic.  The  association  of  rheumatism  and  chorea  is  undoubted, 
and  cannot  be  a  mere  coincidence  ;  not  only  do  we  see  children  suffering 
from  chorea  attacked  with  rheumatism,  and  vice  versa,  but  not  infrequently 
we  see  a  sister  suffering  from  chorea  and  a  brother  from  rheumatism,  or 
attacks  of  chorea  and  rheumatism  alternating  in  the  same  individual. 
Rheumatic  nodules  are  present  in  a  few  cases. 


520  Diseases  of  the  Nervous  System 

The  following"  case  illustrates  the  association  of  chorea  with  rheumatism  : 

A  Case  of  Chorea  attended  by  Paresis  and  loss  of  Speech  for  eighty-one  days,  and  com- 
plicated with  Peri-Endocarditis  and  many  Fibrous  Nodules.  Death  after  8|  months' 
illness. — Edith  M.  N. ,  aged  9  years,  the  daughter  of  a  surgeon,  was  fairly  strong  and 
enjoyed  good  health  till  early  in  June  1889,  when  it  was  noticed  she  had  developed 
decided  choreic  movements ;  for  three  or  four  weeks  previous  to  this  some  premonitory 
symptoms,  such  as  excessive  fidgeiiness,  had  made  their  appearance.  In  the  previous 
September,  eight  months  before  the  beginning  of  the  illness,  she  received  a  severe  fright 
when  away  from  home,  and  since  then  had  been  subject  to  peculiar  nervous  attacks. 
There  is  a  strong  rheumatic  history  in  both  parents.  During  the  early  weeks  of  June  the 
choreic  movements  steadily  increased,  and  were  most  marked  in  the  face  and  right  side  of 
the  body.  Her  speech  was  affected,  and  on  July  19  she  lost  the  power  of  speech,  a  con- 
dition which  lasted  for  eighty-one  days.  About  this  date  she  lost  control  over  her  limbs  ; 
any  attempt  at  voluntary  movement  rendered  the  involuntary  movements  stronger  and 
more  erratic.  She  was  unable  to  change  her  position  in  bed,  and,  indeed,  on  one  occasion 
was  nearly  suffocated  by  slipping  down  the  bedclothes  and  being  unable  to  extricate  her- 
self. On  the  same  date  several  joints  became  tender,  being  most  marked  in  the  right 
elbow  and  wrist.  During  the  next  few  days  the  movements  became  more  violent,  all 
the  hmbs  being  tossed  about,  the  head  jerked  and  banged  from  side  to  side,  and  the 
features  constantly  contorted,  fc-he  was  fed  with  difficulty,  on  account  of  the  movements 
of  the  muscles  of  mastication  and  a  difficulty  of  swallowing.  Early  in  July  a  mitral 
regurgitant  bruit  was  detected,  rheumatic  pains  were  constant,  the  fibrous  nodules  made 
their  appearance.  The  '  rheumatic  '  pains  varied,  sometimes  the  joints  were  tender,  at 
other  times  there  were  shooting  pains  down  the  legs  ;  the  first  nodule  noticed  was  over  one 
of  the  spinous  processes  of  the  cervical  vertebras.  These  nodules  were  followed  by  many 
others,  which  made  their  appearance  during  the  succeeding  two  or  three  months.  At  one 
time  there  were  at  least  200  present,  being  situated  on  the  scalp,  borders  of  the  scapulae, 
along  the  ribs,  tendons  of  the  hands  and  feet.  There  was  one  present  over  each  spinous 
process,  presenting  an  appearance  resembling  Dr.  Cheadle's  illustration  in  the  Lancet, 
May  4,  1889.  They  varied  in  size  from  a  pea  to  a  large  filbert,  and  in  some  places, 
especially  on  the  back  of  the  head,  they  presented  an  almost  bon}^  hardness.  The  choreic 
movements  at  this  time  were  exceedingly  severe,  continuing  both  night  and  day,  the 
patient  obtaining  very  little  rest.  The  tongue  and  mucous  membrane  of  the  cheeks  and 
lips  were  bitten,  and  troublesome  ulcers  resulted.  The  lower  jaw  was  retracted,  appa- 
rently from  spasm  of  the  muscles,  so  that  the  lower  incisors  closed  inside  the  upper  incisors. 
There  were  frequent  involuntary  movements  of  the  bowels  and  bladder.  On  July  12  a 
friction  sound  was  heard  over  the  cardiac  region,  followed  by  a  large  effusion  into  the 
pericardium,  with  a  weak  and  rapid  pulse.  By  the  end  of  July  the  fluid  in  the  pericar- 
dium had  diminished  in  quantity  and  the  dyspnoea  \s^as  less  urgent  than  it  had  been.  The 
choreic  movements  were  less  violent,  but  a  paresis  of  the  extensors  of  the  fingers  and  an 
over-action  of  the  flexors  was  noted,  so  that  a  ball  of  cotton  wool  had  to  be  kept  in  the 
palms  of  the  hands  to  protect  the  skin  from  being  injured  by  the  nails.  Another  note- 
worthy point  was  the  extreme  retraction  of  the  jaw.  The  emaciation  and  exhaustion  had 
now  become  extreme.  In  August  another  attack  of  pericarditis  occurred,  with  effusion, 
and  as  the  fluid  became  absorbed  the  systolic  murmur  noted  a  month  before  became 
louder  ;  there  was  also  a  thrill  and  a  distinct  presystolic  bruit.  The  condition  remained 
much  the  same  during  August  and  the  early  part  of  September  ;  at  this  time  she  was 
kindly  seen  by  Dr.  W.  B.  Cheadle,  of  London.  On  the  evening  of  September  8  the  power 
of  speech  suddenly  returned,  and  from  this  time  she  was  able  to  converse  with  her  friends. 
Later  she  suffered  from  several  fresh  attacks  of  rheumatic  pains  and  violent  attacks  of  pain 
over  the  preecordial  region.  During  the  latter  part  of  September  and  during  the  next  two 
months  gradual  improvement  took  place ;  the  movements  ceased,  the  paresis  of  the  limbs 
disappeared,  and  she  was  able  to  walk  with  help  ;  but  the  heart  evidently  became  more 
and  more  enlarged,  and  the  systolic  bruit  more  marked.  In  January  signs  of  cardiac 
failure  set  in  ;  there  was  enlargement  of  the  liver,  great  anaemia,  dyspepsia,  and  dyspnoea  on 
exertion.  There  were  also  frequent  attacks  of  severe  cardiac  neuralgia,  the  pain  being 
referred  to  the  preecordial  region,  and  there  was  a  sense  of  constriction  round  the  waist. 


Chorea  5^1 

Early  in  I'"ebruary  oedema  of  the  feet  came  on,  while  the  attacks  of  cardiac  pain  were  most 
distressing,  and  continued  till  her  death  on  February  19,  the  illness  having  lasted  nearly 
nine  months  in  all. 

This  case  illustrates  in  a  remarkable  manner  the  close  association  between 
chorea  and  the  rheumatic  state,  and  the  damage  which  the  heart  may  suffer 
in  the  young  without  the  patient  suffering  from  a  typical  attack  of  articular 
inflammation.  Apart  from  the  severe  chorea  from  which  the  patient  suffered, 
there  was  a  continuance  of  the  '  rheumatic  state '  for  several  months,  during 
which  time  there  were  joint  tenderness,  shooting  pains,  acid  perspirations, 
continuous  crops  of  'fibrous  nodules,'  patches  of  erythema,  and  repeated 
attacks  of  carditis.  It  is  evident  that  the  latter  was  chiefly  instrumental  in 
bringing  about  the  fatal  termination,  for  it  was  clear  there  was  not  only  a 
damaged  mitral  valve,  but  also  a  dilated  heart. 

Of  what  prognostic  importance  were  the  large  crops  of  fibrous  nodules  ? 
We  may  certainly  say  they  pointed  to  the  intensity  of  the  '  rheumatic '  state, 
and  the  consecjuent  probability  of  recurrent  attacks  of  peri-endocarditis. 
It  is  worthy  of  note  that  these  nodules  were  mostly  situated  over  prominent 
parts,  and  where,  in  the  choreic  state  of  the  patient,  friction  would  be  most 
intense.  Thus  they  were  present  at  the  back  of  the  head,  over  the  spinous 
processes,  and  along  the  edges  of  the  scapula.  In  the  rheumatic  state, 
as  Dr.  Cheadle  insists,  there  is  a  special  liability  to  irritative  lesions  of  the 
fibrous  tissues  ;  this  is  seen  in  the  nodules — which  are  caused  by  a  prolifera- 
tion, and  cell-infiltration  of  the  fibrous  tissue— and  in  the  endocardial,  peri- 
cardial, and  pleural  inflammations.  If,  as  he  believes,  there  is  a  close  re- 
lationship between  the  fibrous  nodules  and  peri-endocarditis,  the  significance 
of  the  occurrence  of  nodules  cannot  be  overrated.  Perhaps  the  most  inter- 
esting features  in  the  case  were  those  connected  with  the  nervous  system. 
For  nearly  three  months  the  patient  did  not  speak  and  the  only  sounds  made 
consisted  of  a  sort  of  'grunt.'  She  was  perfectly  sensible  and  rational, 
and  would  try  to  nod  or  shake  her  head,  but  any  attempt  at  speaking, 
especially  when  the  chorea  was  at  its  worst,  made  the  involuntary  move- 
ments of  the  face  and  neck  more  violent.  The  cause  of  the  loss  of  speech 
was  doubtless  due  to  a  loss  of  control  over  the  muscles  of  the  tongue  and 
lips.  This  was  also  manifested  in  the  difficulty  of  masticating  food.  The 
power  of  speech  entirely  returned,  and  was  retained  up  to  the  time  of  her 
death.  Another  peculiar  symptom  was  the  retraction  of  the  jaw,  which  was 
well  marked,  apparently  being  caused  by  over-action  of  the  retractor  muscles. 
In  the  later  stages  of  the  choreic  attack,  the  weakness  of  the  arms  and  the 
over-action  of  the  flexors  of  the  fingers  were  well  seen.  The  hands  were 
tightly  clenched,  and  any  attempt  to  force  them  open  gave  pain  and  brought 
on  a  more  convulsive  action  of  the  flexors  of  the  fingers.  There  was  also 
some  rigidity  of  the  legs,  with  pointing  of  the  toes.  At  this  period  there  was 
much  wasting  of  the  muscles,  with  a  certain  amount  of  tenderness  on  pressure 
over  them. 

A  paresis  of  one  arm  not  infrequently  takes  place  in  chorea  ;  such  cases 
having  been  described  as  paralytic  clwrea.  It  consists  in  weakness  rather 
than  paralysis,  and  not  infrequently  precedes  the  other  symptoms  of  chorea. 
A  peripheral  neuritis  in  rare  cases  appears  to  follow  chorea,  as  it  does 
also  rheumatic  attacks,  the  principal  phenomena  being  muscular  wasting 


522  Diseases  of  the  Nervous  System 

and  paresis,  indefinite  pains  such  as  '  pins  and  needles,'  and  in  some  instances 
aiicesthesia. 

In  some  cases  there  is  sufficient  excitement  of  the  brain  to  merit  the 
name  of  maniacal  chorea  or  chorea  insaniens.  This  condition  is  most 
common  at  or  about  puberty.  There  may  be  violent  delirium  and  excite- 
ment, so  that  the  patient  has  to  be  controlled  by  her  attendants,  the  attacks 
resembling  acute  mania.  Often  these  attacks  are  closely  allied  to,  or  resemble, 
hysteria.     The  following  case  appears  to  have  been  one  of  this  kind  : 

Maniacal  Chorea  ;  Hysteria. — The  patient  was  a  girl  of  fourteen  years  of  age  ;  both 
her  sister  and  herself  had  chorea  a  year  and  a  half  before  the  present  attack,  which  lasted 
for  some  time,  and  for  which  she  was  treated  in  the  Derby  Infirmary.  She  was  re-admitted 
with  choreic  movements  of  moderate  intensity,  but  they  were  readily  controlled  by  the  will, 
and  she  was  perfectly  rational.  She  got  worse,  the  movements  being  more  violent  ;  there 
was  difficulty  of  speech,  she  became  extremely  emotional  and  at  times  maniacal.  When 
she  was  moved — as,  for  instance,  when  her  bed  was  made — she  would  struggle  and  run 
her  nails  into  the  attendants.  Two  months  after  admission  the  knees  became  semi-flexed 
and  rigid,  and  there  was  incontinence  of  urine  and  fasces.  She  was  so  troublesome  that 
she  was  sent  home  after  about  three  months  in  hospital.^  Some  time  after  she  was 
admitted  to  the  Children's  Hospital.  At  this  time  she  had  sordes  on  her  lips  and  teeth, 
she  was  much  emaciated  ;  both  knees  were  semiflexed  and  rigid,  the  hips  were  semi- 
flexed and  rigid  ;  the  patellar  reflex  could  not  be  obtained  on  account  of  the  excessive 
rigidity.  There  were  slight  choreic  movements  of  the  arms  and  face  ;  she  passed  her 
urine  and  fseces  into  bed.  She  was  extremely  emotional,  and  there  was  some  hyper- 
sesthesia,  especially  about  the  joints  and  muscles.  She  gradually  began  to  improve  in  a 
week  or  two,  having  more  control  over  the  sphincters,  and  the  legs  became  less  rigid  and 
she  gained  flesh.  A  fortnight  after  admission  the  bedsores  had  healed,  and  she  was  less 
emotional.  In  a  month  she  could  walk  with  help,  and  in  three  months  she  was  discharged 
quite  well. 

In  this  case  there  seems  to  have  been  aggravated  hysteria  associated 
with  chorea,  although  at  one  time  the  girl  looked  very  much  as  if  she  was 
suffering  from  organic  brain  disease.  The  emaciation,  bedsores,  and  rigid 
legs  seemed  to  point  to  an  organic  lesion  ;  this  was,  however,  negatived  by 
her  complete  recovery. 

In  some  rare  cases  instead  of  paresis  there  is  muscular  spasm,  which  may 
persist  for  some  time  after  the  choreic  movements  have  disappeared.  The 
following  case  illustrates  this  : 

Chorea;  Muscular  Spasm. — A  boy,  aged  105  years,  was  admitted  to  the  Children's 
Hospital  suffering  from  chorea,  which  was  attributed  to  a  fright,  he  having  seen  a  '  ghost 
at  a  show.'  Three  sisters  had  also  suffered  from  chorea,  one  having  died  during  an  attack. 
His  attack  was  a  moderate  one  ;  no  bruit  was  heard,  there  was  some  paresis  of  his  right 
leg.  He  was  discharged  in  a  month's  time  quite  well.  He  was  re-admitted  two  months 
later,  the  choreic  movements  being  pretty  much  confined  to  the  right  arm,  which  was 
markedly  weak  :  the  right  knee  joint  and  ankle  were  rigid,  the  muscles  being  in  a  state  of 
spasm  ;  there  was  no  pain  or  tenderness.  There  was  a  S3-stolic  bruit  at  the  apex.  He  was 
discharged  in  six  weeks  ;  the  choreic  movements  had  disappeared,  but  the  spasm  in  the 
right  leg  persisted.  He  had  another  attack  of  chorea  eighteen  months  afterwards  ;  before 
this  occurred,  the  muscular  spasm  had  entirely  disappeared. 

Hemichorea.—  In  many  cases,  as  already  pointed  out,  the  movements 
are  confined  to  one  side  of  the  body,  or  at  all  events  they  are  more  marked 
on  one  side  than  the  other.     Hemichorea  is  in  some  instances  post-hemi- 

^  These  notes  w  ere  kindly  furnished  by  Dr.  W.  Benthall,  of  Derby. 


Chorea  523 

plegic,  following-  some  months  or  more  after  the  hemiplegia,  when  contrac- 
tures are  present,  as  in  the  case  of  cerebral  tumours  situated  near  and 
involving  the  internal  capsule  or  pyramidal  tracts  :  choreiform  movements 
may  take  place  on  the  opposite  side.  In  hemichorea  symptomatic  of  brain 
disease  the  movements  are  vigorous  and  grotesque,  the  fingers,  hands,  feet, 
and  extremities  being  twisted  and  jerked  about.  In  one  of  our  cases,  in  a 
boy  of  five  years  of  age,  who  had  a  cheesy  tumour  in  the  right  optic  thalamus, 
at  first  sight  the  child  appeared  to  be  affected  with  the  ordinary  form  of 
chorea.  His  left  arm  was  in  constant  movement,  the  result  of  short,  irregular, 
jerky  contractions  of  the  muscles  of  the  forearm  and  arm,  following  one 
another  with  great  rapidity,  and  closely  resembling  those  seen  in  a  severe 
case  of  choi^ea.  When  the  boy  was  at  rest  the  arm  was  quiet,  only  a  sort  of 
fumbling  movement  of  his  hand  being  noticed,  but  on  asking  him  to  sit  up 
or  give  his  hand,  vigorous,  almost  violent,  movements  began  again.  Some  of 
the  movements  were  produced  by  all  the  muscles  of  the  arm,  yet  some  of  the 
muscles  acted  more  continuously  and  powerfully  than  others,  so  that  the 
arm  tended  to  be  held  to  the  side  and  more  or  less  behind,  while  the  fore- 
arm was  pronated  and  the  wrist  flexed,  the  fingers  being  in  continual  move- 
ment. This  condition  of  hemichorea  differs  from  'athetosis'  or  'mobile' 
spasm  already  described  (p.  556). 

Morbid  Anatomy. — Various  minute  changes  have  been  described  in  the 
brain  in  fatal  cases  of  chorea,  but  it  is  quite  certain  that  no  constant  and 
invariable  lesion  has  been  discovered.  Embolism  and  thrombosis  of  the 
minute  vessels  of  the  cortex  and  basal  ganglia  have  been  described  ;  minute 
spots  of  softening,  changes  in  the  nerve  cells,  and  enlarged  perivascular 
spaces  have  also  been  found.  We  cannot  say  that  any  of  these  observations 
throw  any  light  on  the  morbid  anatomy  of  the  disease,  especially  when  we 
remember  that  on  various  occasions  competent  observers  have  found 
nothing  of  importance  in  their  examination  of  the  brain  and  spinal  cord  in 
fatal  cases.  Many  of  the  changes  described  are  no  doubt  secondary,  the 
result  of  hypersemia  of  the  nervous  centres. 

The  frequent  association  of  chorea  with  rheumatism  and  endocarditis 
suggested  to  Kirkes  the  idea  that  chorea  was  the  result  of  minute  embolism 
of  the  brain  by  fragments  of  fibrin  washed  off  the  mitral  valves.  This 
hypothesis,  however,  is  quite  inadequate  to  explain  the  phenomena  presented 
by  the  disease  ;  thus  chorea  has  followed  within  a  few  hours  of  a  sudden 
fright,  and  moreover  fatal  cases  have  been  recorded  (though  rarely)  in  which 
no  endocarditis  has  been  found.  Embolism  will  not  explain  those  cases  of 
'  reflex  chorea '  in  which  the  exciting  cause  is  an  acute  otitis,  or  when  chorea 
follows  some  injury  or  accompanies  pregnancy  ;  we  find  that  pericarditis,  and 
perhaps  endocarditis,  act  as  exciting"  causes  operating  through  the  nervous 
system,  just  in  the  same  way  as  some  gastric-intestinal  irritation  may  be  the 
exciting  cause  of  convulsions  in  infants. 

In  considering  the  pathology  of  chorea  we  must  take  into  account  the 
associations  of  chorea,  though  it  cannot  be  said  they  help  us  much  in  coming 
to  a  conclusion.  Chorea  is  associated,  on  the  one  hand,  with  rheumatism 
and  endocarditis,  and  on  the  other  with  hysteria  and  mania  ;  the  former 
association  would  suggest  a  blood-change,  the  latter  simply  a  functional 
disturbance    of  the    nervous    system.      Pathologists    in    formulating    their 


524  Diseases  of  the  'Nervous  System 

theories  have  leaned  either  to  the  one  or  to  the  other.  Sometimes  chorea 
has  been  explained  as  secondary  to  endocarditis,  as  a  result  of  capillary 
embolism,  or  as  the  result  of  a  '  rheumatic '  condition  of  blood,  in  which 
some  chemical  poison  has  been  present  in  the  blood  which  has  a  specific 
action  on  the  nervous  system.  At  other  times  chorea  has  been  looked  upon 
as  an  emotional  disease,  and,like  hysteria,  a  purely  functional  disease,  or,  as 
it  has  been  termed,  an  '  insanity  of  the  muscles '  or  motor  region  of  the  brain, 
just  as  mania  or  other  forms  of  insanity  affect  the  seat  of  the  mind. 

There  has  been  also  much  difference  of  opinion  with  regard  to  the  seat 
of  the  disease  ;  it  has  been  placed  in  the  spinal  cord,  basal  ganglia,  and 
cortex  of  the  brain.  The  fact  that  the  face  is  usually  affected,  and  that  more- 
over the  choreic  movements  are  frequently  one-sided,  would  almost  certainly 
point  to  the  seat  of  the  disease  being  within  the  cranium.  The  tendency  of 
recent  researches  in  physiology  has  been  to  deprive  the  corpus  striatum  of  its 
alleged  function  as  an  originator  or  co-ordinator  of  motor  influences,  and  to 
assert  that  it  has  little  or  nothing  to  do  with  the  discharges  of  motor  force. 
On  the  other  hand,  there  is  strong  reason  to  believe  that  the  choreic  move- 
ments are  the  result  of  irregular  discharges  from  the  motor  region  of  the 
cortex  ;  for  the  time  being  the  will  or  the  inhibitory  influence  of  the  frontal 
regions  is  in  abeyance,  and  irregular  purposeless  discharges  are  given  out 
from  the  cells  in  the  motor  region  of  the  cortex.  There  is  much  reason  to 
believe  that  the  functions  of  the  cortex  are  impaired  in  chorea,  as  shown  not 
only  by  the  spasmodic  movements,  but  also  by  the  paresis  which  sometimes 
occurs,  and  the  mental  dulness  and  emotional  disturbance  so  often  present. 
It  can  easily  be  understood  that  if  there  is  impaired  nutrition  of  the  nerve 
centres,  a  sudden  fright,  or  an  irritation  at  some  distant  part,  may  start  the 
irregular  discharges  from  the  cortex,  which  it  may  soon  be  beyond  the  power 
of  the  will  to  control. 

With  regard  to  the  cardiac  complications  found  in  fatal  cases  we  cannot 
do  better  than  quote  Dr.  Sturges,  who  sums  up  as  follows  :  '  Vegetations,  new 
or  old,  on  the  auricular  surface  of  the  mitral  valves,  with  or  without  similar 
deposits  on  the  aortic  valves,  and  sometimes  with  pericarditis,  are  met  with 
in  the  great  majority  of  cases  dying  of,  or  with,  or  shortly  after,  chorea. 
This  condition,  however,  does  not,  as  a  rule,  contribute  directly  to  the  fatal 
issue  ;  it  is  found  equally  among  those  that  die  with  and  those  that  die  of 
chorea,  and  in  some  of  the  most  marked  and  typical  cases  of  fatal  chorea 
the  valves  of  the  heart  have  been  found  absolutely  healthy.' 

Diagnosis. — This  is  not  usually  difficult,  though  it  must  always  be  borne 
in  mind  that  the  choreic  movements  present  may  be  symptomatic  of  some 
serious  brain  lesion,  or  of  some  distinct  disturbing  influence,  such  as 
pericarditis.  We  have  seen  on  one  or  two  occasions,  in  girls  about  puberty, 
choreic  movements  followed  by  emotional  disturbance  and  paresis  of  limbs, 
attributed  not  unnaturally  to  hysteria,  where  the  onset  of  optic  neuritis  and 
amblyopia  has  made  it  clear  that  the  case  was  really  one  of  cerebral 
tumour.  We  have  seen  also  the  onset  of  chorea  in  a  girl  of  four  years  followed 
in  a  week  by  pericarditis  and  death  in  a  few  days. 

Any  brain  lesion  which  presses  upon  the  pyramidal  tract  may  give  rise  to 
movements  similar  to  chorea  ;  we  have  several  times  seen  this  in  cheesy 
tumours  of  the  optic  thalamus  which  compressed  the  internal  capsule  ;  in 


Chorea  525 

such  cases  a  '  hemichorea  '  is  produced  (see  p.  522).  It  must  be  borne  in 
mind  that  in  true  chorea,  if  at  all  intense,  the  movements  are  general,  though 
perhaps  worse  on  one  side  than  on  the  other,  but  they  are  never  confined  to 
one  side,  as  in  the  case  of  cerebral  tumour. 

In  some  of  the  special  varieties  of  the  disease  the  diagnosis  may  be 
difficult  ;  thus  in  the  case  related  (p.  522),  where  there  was  contraction  of  the 
limbs  and  bedsores,  one  might  readily  assume  that  chronic  meningitis  or 
other  cerebral  lesion  was  present.  In  a  case  under  our  care,  where  tuber- 
cular meningitis  supervened  in  the  course  of  chorea,  the  diagnosis  was  un- 
certain for  a  few  days.  The  presence  of  optic  neuritis  would  strongly 
point  to  organic  disease,  though,  as  already  stated,  Gowers  has  observed 
optic  neuritis  in  a  case  of  chorea.  In  cases  of  paralytic  chorea  the  chief 
symptom  may  be  simply  paresis  of  one  arm  ;  but  usually  a  slight  exam- 
ination will  detect  short  clonic  spasms,  either  in  the  affected  arm  or 
elsewhere. 

Prognosis. — Recovery  follows  in  the  vast  majority'  of  instances.  The 
principal  danger  is  from  some  heart  complication,  as  pericarditis,  and  from 
exhaustion  in  consequence  of  the  violence  of  the  movements,  want  of  sleep, 
and  nourishment.  The  more  severe  the  case,  the  longer  will  be  its  duration. 
Maniacal  and  hysterical  choreic  cases  are  usually  very  chronic. 

Treatnieitt. — The  most  important  element  in  the  treatment  of  chorea  is 
rest.  It  is  necessary  to  secure  for  a  patient  suffering  from  chorea  complete 
rest  for  the  body,  and  complete  absence  of  excitement  of  all  kinds.  In  all 
but  the  mild  cases  it  is  well  to  begin  the  treatment  by  keeping  the  patient 
for  a  few  days  or  a  week  in  bed  completely  at  rest.  \\"e  must  bear  in  mind 
that  voluntary  movements  of  all  kinds  (in  severe  cases  at  least)  make  the 
involuntary  movements  more  marked  and  more  completely  beyond  the 
control  of  the  will.  On  the  other  hand,  the  movements  cease  during  sleep, 
and  the  more  quiet  a  patient  can  be  kept,  the  better  chance  there  is  of  a 
better  nutrition  of  the  body  and  the  nervous  centres.  Any  excitement  or 
mental  effort  is  certain  also  to  make  matters  worse,  so  that  all  forms  of 
mental  work  must  he  avoided,  while  the  surroundings  of  the  patient  must  be 
made  as  agreeable  as  possible.  When  the  movements  are  severe,  so  that 
the  patient  cannot  sleep,  some  narcotic  must  be  prescribed,  and  of  remedies 
of  this  class  chloral  is  probably  the  best,  but  it  must  be  given  in  full  doses 
to  be  of  use.  Ten  or  fifteen  grains  may  be  given,  and  repeated  in  four  hours 
if  the  restlessness  continues.  Bromide  of  potassium  may  be  combined  with 
the  chloral,  though  most  agree  that  chloral  is  more  useful  than  the  bromide. 
Morphia  seems  at  times  to  add  to  the  excitement  present,  though  in  some  cases 
it  acts  better  than  chloral.  In  the  case  recorded  on  p.  520  (girl  aged  nine 
years'),  chloral  and  bromide  entirely  failed.  Nepenthe  in  lo-minim  doses 
gave  sleep  ;  later  in  the  disease  as  much  as  30  minims,  and  on  one  occasion 
70  minims,  were  given  in  one  night.  This  was,  of  course,  only  after  a  toler- 
ance of  the  drug  had  been  established.  Inhalations  of  chloroform  are  often 
useful  to  get  the  patient  off  to  sleep.  Great  care  must  be  taken  to  prevent 
the  patient  from  injuring  herself  by  tumbling  out  of  bed,  and  it  may  be 
necessary  to  protect  the  limbs  by  wrapping  them  up  in  cotton  wool,  or  to 
surround  them  with  some  soft  material  ;  or  padded  boards  may  be  placed  on 
each  side  of  the  bed,  or  a  mattress  may  be  placed  on  the  lioor.     The  patient 


526  Diseases  of  the  Nervous  System 

should  be  given  a  fair  amount  of  liquid  nourishment,  and  also  stimulants. 
Frequent  spongings  are  of  great  value  in  getting  the  skin  to  act  and  calming 
the  patient. 

Even  in  the  less  severe  cases  of  chorea  it  is  well  to  confine  the  patient  to 
bed  for  a  week  or  two  in  the  early  stages  ;  the  movements  are  always  less 
when  the  child  is  at  rest  in  bed,  and  these  means  are  almost  certain  to  shorten 
the  duration  of  the  attack.  When  improvement  occurs  the  patient  may  be 
allowed  to  get  up  for  a  few  hours  a  day  and  be  taken  out  into  the  fresh 
air,  but  too  much  exercise  should  be  prevented. 

The  drug  which  is  most  used  at  the  present  time  is  arsenic  ;  sulphate  or 
oxide  of  zinc,  cannabis  indica,  iron,  Calabar  bean,  and  conium  have  also  been 
used.  We  confess  to  some  scepticism  with  regard  to  the  value  of  medicines 
in  chorea,  and  feel  sure  they  occupy  only  a  subsidiary  place  in  treatment. 
Arsenic  is  certainly  of  use  in  the  dyspeptic  conditions  which  so  often 
accompany  chorea,  but  it  requires  to  be  given  in  increasing  doses  as  the 
stomach  becomes  more  and  more  accustomed  to  it.  Two-  or  three-minim 
doses  may  be  given  three  times  a  day  at  first,  and  increased  at  the  rate  of 
an  extra  minim  every  week  till  six  or  seven  minims  are  given.  It  is  better 
not  to  continue  the  administration  for  too  long  together,  as  a  temporary 
darkening  of  the  skin  is  apt  to  take  place.  The  administration  may  be 
omitted  for  a  week  or  two,  and  then  recommenced.  In  the  latter  stages  iron 
may  be  useful,  given  in  combination  with  arsenic.  Great  care  should  be 
taken  to  regulate  the  bowels  ;  constipation  is  the  rule,  and  this  may  be 
overcome  by  small  pilules  of  extract  of  aloes  or  some  elixir  of  cascara 
sagrada. 

In  chronic  cases  a  change  of  scene,  such  as  residence  at  the  seaside,  is 
often  suggested  by  the  friends,  but  in  our  experience  this  change  often 
makes  the  movements  worse  and  prolongs  the  attack,  in  consequence  of 
the  excitement  attending  the  change  and  the  patient  attempting  to  do  more 
than  her  strength  permits.  A  change  to  the  seaside  should  be  deferred  till 
the  movements  have  nearly  ceased  and  can  be  controlled  entirely  by  the  will. 
The  same  may  be  said  of  gymnastic  exercises  and  rhythmical  movements  ; 
they  are  of  the  greatest  use  when  the  movements  tend  to  become  habitual, 
while  the  health  of  the  patient  is  good  ;  they  are  certainly  not  desirable  in  the 
earlier  stages.  Massage  has  been  employed  with  good  result  by  Goodhart 
and  Phillips,  and  in  some  of  our  own  and  our  colleagues'  cases  the  result 
has  been  satisfactory.  All  through  the  course  of  chorea  moral  treatment  is 
of  the  greatest  importance.  Chorea  in  many  cases  is  closely  allied  to  hysteria, 
and  a  firm  but  kindly  demeanour  towards  the  patient  is  cahed  for  ;  and  she 
should  be  encouraged  to  control  the  movements  as  much  as  possible  by  an 
effort  of  will.  In  all  severe  cases  a  nurse  should  be  provided,  as  the  patient's 
mother  is  often  the  last  person  who  should  have  charge  of  her. 

In  all  stages  of  the  attack  a  nourishing,  easily  digested  diet  is  necessary  ; 
in  severe  cases  it  is  necessary'  to  feed  the  patient  ;  in  such  patients  fluid  food 
only  can  be  administered. 

Epilepsy 

Convulsive  seizures  of  various  degrees  of  severity  are  common  during 
childhood  and  youth,  and  when  they  are  idiopathic— that  is,  without  assign- 


Epilepsy  527 

able  cause,  no  cerebral  or  other  lesion  being  discoverable — the  term 
'epileptic '  is  applied  to  them.  It  is  difficult  to  say  in  what  proportion  of 
cases  children  who  suffer  from  convulsions  during  infancy  become  confirmed 
epileptics  ;  certainly  the  majority  of  those  who  suffer  from  infantile  con- 
vulsions lose  this  tendency  to  convulsive  seizures  as  they  grow  older.  In 
only  about  \2\  per  cent,  of  cases  of  chronic  epilepsy  is  there  a  history  of 
the  fits  commencing  during  the  first  three  years  of  life,  and  in  a  smaller 
percentage  (5^^)  during  the  first  year.  (Cowers.)  According  to  statistics 
collected  by  Cowers,  in  one-fourth  of  the  total  number  the  attacks  begin 
before  the  age  of  ten  years,  and  nearly  one-half  between  the  ages  of  ten  and 
twenty  years.  These  statistics  show  that  there  is  always  the  possibility  that 
children  or  infants  who  suffer  from  reflex  convulsions  may  become  epileptics  ; 
yet  there  is  a  strong  probability,  if  the  child  does  not  suffer  from  any  cerebral 
defect,  or  has  no  hereditary  tendency  in  the  direction  of  epilepsy,  that  he  will 
not  grow  up  an  epileptic.  Hereditary  influences  certainly  predispose  ;  a 
family  history  of  epilepsy  or  insanity  is  obtained  in  about  one-third  of  the 
cases  of  epilepsy,  in  others  it  may  be  found  that  they  come  of  neurotic 
families  in  which  members  have  suffered  from  chorea  or  hysteria. 

Of  the  exciting  causes  there  is  little  to  be  said.  The  first  fit  may  be 
described  by  the  friends  as  being  due  to  a  '  sunstroke,'  or  a  '  blow  on  the 
head,'  or  a  'fright  ;'  but  it  is  unsafe  to  place  much  reliance  on  such  state- 
ments, as  they  may  be  merely  coincidences,  and  certainly  are  not  sufficient 
in  themselves  to  produce  epilepsy.  In  the  large  majority  of  cases,  it  must  be 
confessed,  no  immediate  cause  can  be  discovered.  Epilepsy  sometimes 
commences  after  scarlet  fever  and  other  zymotic  diseases,  but  beyond  the 
fact  that  these  fevers  leave  a  certain  amount  of  weakness  behind,  and  so  may 
predispose,  there  is  nothing  to  suggest  that  they  act  as  effectual  causes.  The 
approach  of  puberty  is  a  time  when  the  nervous  system  is  in  an  excitable 
state,  especially  in  girls,  and  epileptic  fits  are  very  apt  to  commence  at  this 
period,  notably  in  cases  where  menstruation  does  not  commence  at  the 
usual  period,  but  is  delayed  by  any  cause.  Constipated  bowels  and  a  slug- 
gish condition  of  liver  certainly  act  as  predisposing  causes. 

Symptoms. — Two  forms  of  attack  are  usually  described  :  the  minor  form, 
ox  petit  thai.,  and  the  major  form,  ox  grand  mal ;  but  these  two  forms  insen- 
sibly pass  into  one  another,  and  there  is  no  marked  line  of  demarcation 
between  them. 

The  precursory  symptoms  differ  very  much  :  frequently  the  first  fits  and 
the  succeeding  fits  come  in  the  midst  of  perfect  health,  and  neither  the 
patient  nor  his  friends  are  aware  that  a  fit  is  imminent.  On  the  other  hand, 
the  child  may  be  unusually  irritable,  easily  put  out,  and  nothing  pleases  it  ; 
it  may  be  feverish,  dull,  and  stupid.  In  some  cases  the  fit  is  preceded  by 
some  warning  or  aura,  by  which  the  patient  becomes  aware,  by  past 
experience,  that  an  attack  is  at  hand.  These  aurse  are  moi-e  common  in 
adults  than  in  children,  or  at  any  rate  adults  are  better  able  to  describe  their 
feelings  and  have  a  larger  experience  of  fits  to  fall  back  upon.  The  aurae  are 
very  diverse  in  character  :  they  may  be  sensations  referred  to  an  arm  or  leg, 
or  to  the  throat  ;  there  may  be  headache,  vertigo,  or  faintness. 

Petit  mal. — These  minor  attacks  are  very  slight  in  character  and  are 
often  not  admitted  to  be  epileptic  by  the  friends,  who  usually  connect  'fits' 


528  Diseases  of  the  Nervous  System 

with  the  more  severe  and  decided  form  of  seizure.  They  are  often  spoken 
of  as  '  faints  '  or  '  attacks.'  There  may  be  no  real  convulsion  or  tonic  spasm  ; 
the  child  may  stumble  when  walking  from  a  momentary  impairment  of 
consciousness  ;  a  peculiar  look  crosses  its  face,  and  for  a  moment  it  is  dazed 
and  forgets  what  has  happened.  Sometimes  the  face  becomes  pallid  for 
a  moment,  and  there  is  a  slight  convulsive  spasm  of  the  facial  or  other 
muscles.  The  urine  is  rarely  passed  in  these  seizures,  nor  is  there  any  cry. 
Sometimes  the  attack  is  succeeded  by  drowsiness  or  stupor.  In  older 
children  the  behaviour  may  be  very  peculiar  ;  after  one  of  these  minor 
seizures  a  mild  mania  may  seize  the  patient,  he  becomes  mischievous  or 
strikes  other  children  without  provocation,  or  behaves  in  an  hysterical 
manner. 

Grand  vial. — The  seizure  may  begin  with  a  sharp  cry  or  scream,  as  of 
sudden  fright  ;  in  many  cases  this  cry  is  absent,  the  patient  falling  precipi- 
tately onto  the  ground  in  an  unconscious  state.  The  face  is  pallid  and 
tonic  spasms  of  the  muscles  begin.  Sometimes  these  are  one-sided  in  dis- 
tribution :  the  muscles  of  one  side  of  the  face,  neck,  arm,  and  leg  of  the  same 
side  are  thrown  into  contraction,  the  head  is  usually  rotated  to  the  affected 
side,  In  other  cases  the  spasms  are  general.  The  legs  are  usually  extended 
and  stiff,  the  elbows  partially  bent,  the  wrists  flexed,  and  the  fingers  in  a 
position  of  interosseous  spasm.  (Gowers.)  The  respiratory  muscles  join 
in  the  general  tonic  spasm,  and,  as  the  inspiratory  muscles  are  more  powerful 
than  the  expiratory,  the  breath  is  drawn  in  and  held,  so  that  the  face  becomes 
congested  and  the  lips  blue.  There  is  usually  spasmodic  contraction  of  the 
muscles  of  the  jaw,  so  that  the  tongue  is  bitten  and  held  between  the  teeth  ; 
frothy,  perhaps  blood-stained,  saliva  runs  from  the  patient's  mouth.  Death 
may  take  place  from  asphyxia  during  this  stage.  Usually,  however,  after 
the  stage  of  tonic  spasm  has  lasted  from  a  few  to  thirty  seconds,  the  con- 
tinued spasm  of  the  muscles  relaxes,  and  clonic  or  intermittent  short  con- 
tractions succeed.  The  muscles  of  the  face  twitch,  so  that  the  patient 
appears  as  if  he  were  making  grimaces  ;  the  limbs  '  work,'  alternately  flexing 
and  extending — sometimes  so  violently  that  the  head  and  legs  are  banged 
about  and  become  bruised  and  Injured.  In  other  cases  the  clonic  spasm  is 
not  so  vigorous,  there  being  only  short,  sharp,  muscular  contractions.  The 
urine  and  sometimes  the  feeces  are  passed.  The  period  of  the  clonic  spasm 
is  variable  ;  it  may  last  many  minutes,  or  even  hours  ;  the  patient  gradually 
recovers  consciousness,  and  lias  no  recollection  of  what  has  passed.  He 
probably  is  dazed  and  sleepy,  goes  off  to  sleep,  and  wakes  up  tired  and  sore. 
The  fits  vary  much  in  intensity  :  often  the  stage  of  tonic  spasm  is  short  and 
not  well  marked,  and  the  whole  duration  of  the  fit  is  not  more  than  half-  a 
minute.  In  some  cases,  especially  after  severe  attacks,  a  temporary  para- 
lysis, mostly  hemiplegic,  is  left.  We  are  incHned  to  attribute  this  to  a 
meningeal  haemorrhage  which  has  taken  place  during  the  respiratory  spasm. 

Hysteroid  Pits. — Some  minor  attacks  closely  resemble  hysteria  in  that 
the  spasmodic  movements  are  of  a  purposeful  character,  as  if  directed  by 
the  will,  and,  moreover,  the  child  appears  to  be  conscious  or  semi-conscious 
during  the  fit.  This  form  of  seizure  is  common  both  in  boys  and  girls. 
The  phenomena  which  take  place  are  exceedingly  various  ;  the  child  may 
commence  by  barking  Hke  a  dog,  or  mewing  like  a  cat,  or  may  attempt  to 


Epilepsy  529 

bite  its  attendants  ;  the  head  may  be  banged  about  and  the  legs  and  arms 
thrown  wildly  about,  as  if  the  child  were  directing  the  movements.  The 
patient  may  stiffen  out  and  arch  his  back  as  in  opisthotonos.  Sometimes 
the  actions  are  still  more  co-ordinated.  Thus  in  a  girl  of  seven  years,  in 
hospital,  when  an  attack  came  on  she  would  jump  up  in  bed,  turn  round 
once  or  twice,  sit  down  again  and  arrange  the  bedclothes,  smoothing  them 
carefully  down,  and  yet  be  unconscious  during  the  fit,  and  have  no  remem- 
brance of  it  afterwards.  A  sharp  word  or  the  prick  of  a  pin  will  often 
arrest  these  fits.  That  some  of  these  cases  are  closely  related  to  epilepsy  is 
shown  by  the  fact  that  they  may  alternate  with  true  epileptic  fits  or  they  may 
supervene  at  puberty  in  children  who  have  suffered  from  chronic  epilepsy. 

Post-hemipleg-ic  Epilepsy. — Children  who  suffer  from  hemiplegia  which 
dates  from  birth  or  within  a  year  or  two  of  birth  are  very  apt  to  suffer  from 
epileptiform  attacks.  Convulsions  are  also  very  apt  to  attend  the  onset  of  the 
hemiplegia  :  the  child  may  continue  to  have  fits,  and  be  subject  to  them  for 
the  rest  of  its  life.  In  other  cases  a  period  of  months  or  years  may  elapse 
between  the  onset  of  the  hemiplegia  and  the  commencement  of  the  epileptic 
fits.  It  is  often  about  puberty  that  they  recur.  As  a  rule,  the  convulsions 
affect  the  paralysed  side  only,  but  in  severe  cases  the  convulsions  may  be 
general.  An  aura  or  warning  of  the  approaching  fit  is  more  common  in 
post-hemiplegic  epilepsy  than  in  idiopathic  epilepsy.  In  these  cases  it  is 
common  for  mental  backwardness  to  exist  (see  case,  p.  556). 

Course. — As  already  stated,  the  epileptic  fits  may  date  from  infancy,  the 
child  having  suffered  in  the  early  months  or  years  of  its  life  from  convul- 
sions, and  these  have  been  succeeded  by  chronic  epilepsy.  More  often  the 
child  has  been  free  from  convulsive  seizures  during  infancy  and  early  child- 
hood, and  it  is  only  during  the  second  dentition  or  as  puberty  is  approached 
that  it  has  begun  to  suffer  from  fits.  The  health  prior  to  the  commence- 
ment of  the  fits  may  have  been  excellent,  there  may  be  no  history  of  epilepsy 
in  the  family,  and  it  may  be  quite  impossible  to  explain  the  onset  of  epileptic 
fits.  At  first  the  friends  are  loth  to  believe  the  fits  to  be  epileptic,  and  attri- 
bute them  to  rapid  growth,  dentition,  weakness,  or  some  injury.  In  other 
cases  the.  health  may  have  been  indifferent  or  the  temperament  peculiar, 
the  child  having  been  of  a  strange  disposition,'  nervous,  easily  frightened, 
morose,  or  backward  in  mental  development,  or  may  have  shown  signs  ot 
idiocy,  and  then,  as  puberty  approaches,  commences  with  epileptic  fits.  The 
health  of  the  child  after  the  commencement  of  the  fits  varies  according  to 
their  frequency  and  severity.  In  the  milder  forms  the  children  may  enjoy 
the  best  of  health,  may  be  merry,  romping  children,  able  to  take  their  part 
in  rough  school  games,  and  be  of  average,  or  more  than  ordinary,  quickness 
and  intelligence.  In  other  cases,  especially  when  the  fits  occur  frequently, 
the  health  suffers,  the  patient  becomes  sallow  and  ansemic,  his  digestion 
and  appetite  are  poor,  and  the  liver  and  bowels  sluggish.  The  memory  is 
apt  to  fail  more  or  less,  and  in  the  worst  cases  a  condition  allied  to  dementia 
may  supervene.  The  intervals  between  the  fits  differ  considerably,  not  only 
in  different  patients,  but  in  the  same  individual ;  sometimes  many  months  or 
even  years  will  pass  without  a  fit,  at  other  times  the  fits  follow  one  another 
at  intervals  of  a  few  minutes,  so  that  the  patient  is  no  sooner  out  of  one  fit 
than  he  is  into  another.    To  this  latter  condition  the  term '  status  epilepticus  ' 

M  M 


530  Diseases  of  the  Nervous  System 

has  been  applied.  In  the  petit  tnat  the  fits  usually  occur  oftener  than  in 
the  more  severe  attacks.  Fits  may  occur  at  any  time  in  the  twenty-four 
hours,  at  night  or  by  day,  but  there  seems  to  be  a  special  tendency  for  them 
to  recur  in  the  early  morning  when  the  patient  is  getting  up. 

Prognosis. — The  prognosis  is  bad  in  those  who  have  suffered  from  fits 
from  infancy,  and  who  are  mentally  deficient,  or  in  whom  some  mental 
change  has  taken  place.  The  chance  of  the  entire  cessation  of  the  fits  is  a 
poor  one  in  those  who  have  fits  frequently.  The  less  frequent  the  fits,  the 
greater  is  the  probability  that  they  may  cease  altogether.  Even  in  those  who 
have  only  suffered  from  fits  at  long  intervals  a  cautious  prognosis  must  be 
given,  as  those  who  have  so  suffered  are  never  safe,  and  a  recurrence  may 
at  any  time  take  place.  The  danger  to  life  is  least  in  the  minor  attacks,  but 
as  time  goes  on  the  major  attacks  may  supervene.  There  is  always  the 
possibility  that  the  fits  may  cease  when  the  epoch  of  puberty  is  passed,  and 
in  the  case  of  girls  when  menstruation  is  thoroughly  established.  It  must 
always  be  borne  in  mind  that  epileptics  may  at  any  time  meet  with  a  sudden 
death  from  injuries  received  during  a  fit  :  they  may  fall  into  the  fire,  or  into 
water,  or  they  may  be  suffocated  in  bed  at  night.  Less  often  death  takes 
place  in  the  fit  from  asphyxia,  due  to  prolonged  spasm  of  the  glottis  and 
respiratory  muscles. 

Diagnosis. — In  some  cases  oi petit  mat  the  attack  maybe  so  slight  that  a 
doubt  may  exist  whether  the  fits  are  really  epileptic  or  not  ;  but  all  recurring 
'  faints '  or  attacks  of  giddiness  must  be  looked  upon  with  great  suspicion, 
and  if  there  is  a  loss  of  consciousness,  however  short,  they  are  almost 
certainly  epileptic.  Difficulty  may  often  arise  in  distinguishing  hysterical 
attacks  from  true  epilepsy,  especially  the  attacks  described  as  hysteroid.  It 
may  be  simply  a  matter  of  opinion  whether  some  of  these  attacks  are  best 
classed  with  epilepsy  or  hysteria  ;  in  any  given  case  careful  inquiry  must  be 
made  for  typical  epileptic  fits,  which  sometimes  occur  immediately  before 
the  hysteroid  fits.  The  diagnosis  is  usually  easy  between  typical  epileptic 
and  typical  hysterical  fits  ;  it  is  often  very  uncertain  in  atypical  ones.  Loss 
of  consciousness,  biting  the  tongue,  or  tonic  followed  by  clonic  spasms,  if 
present,  are  decisive  in  favour  of  epilepsy.  There  may  often  be  considerable 
difficulty  in  distinguishing  between  reflex  convulsions  and  epileptic  fits. 
Under  three  years  of  age,  if  there  are  the  signs  of  rickets,  the  probabilities 
are  strongly  in  favour  of  their  being  reflex.  After  this  age  reflex  con- 
vulsions may  occur  at  the  commencement  of  some  zymotic  disease,  or 
possibly  as  the  result  of  cutting  the  permanent  teeth,  or  from  worms  ;  but  the 
chances  are  immensely  in  favour  of  epilepsy  if  they  are  on  the  type  of  those 
in  idiopathic  epilepsy ;  in  all  cases  where  the  attacks  are  epileptiform  in 
character,  in  which  there  is  loss  of  consciousness,  spasm  followed  by  stupor, 
even  though  the  child  is  cutting  one  of  the  permanent  teeth  or  had  worms, 
we  should  be  inclined  to  Iselieve  they  are  really  epileptic.  Parents  naturally 
like  to  believe  that  the  fits  are  due  to  dentition,  to  rapid  growth,  to  a  dis- 
ordered liver  or  stomach,  especially  in  those  cases  where  there  are  no  here- 
ditary tendencies  present,  but  we  cannot  accept  these  as  anything  more  than 
exciting  causes,  and  in  all  such  cases  there  is  only  too  much  reason  to  fear 
that  there  may  be  a  recurrence  of  the  attacks.  Convulsions  may  occur  as  the 
result  of  brain  disease,  recent  as  well  as  old.     A  tumour  or  syphilis  may  be 


Epilepsy  531 

present  in  this  case  ;  there  may  be  some  marked  aura,  especially  visual  or 
auditory ;  the  convulsions  will  be  mostly  one-sided  ;  moreover,  there  is 
headache,  giddiness,  vomiting,  paralysis,  and  optic  neuritis. 

Treatment. — A  child  subject  to  epileptic  fits  should  be  placed  under  the 
most  favourable  conditions  possible,  and  should  be  most  carefully  guarded 
from  excitement,  over-fatigue,  and  over-feeding.  A  healthy  country  life,  with 
plenty  of  outdoor  exercise  and  sufficient  employment  for  the  mind,  must  be 
enjoined.  A  moderate  amount  of  brain  work  may  be  allowed,  but  no  forcing 
of  any  kind  should  be  permitted.  It  is  well  to  allow  no  work  and  not  much 
exercise  before  breakfast,  as  at  this  time  there  appears  to  be  an  especial 
liability  to  fits.  The  diet  should  be  simple  and  unstimulating  ;  in  some  cases 
coming  under  our  notice  children  have  done  better  when  butcher's  meat 
has  been  excluded  from  their  diet  or  only  taken  sparingly.  How  useful  a 
regular  life  is,  is  seen  by  the  improvement  which  nearly  always  takes 
place  on  the  child's  admission  to  hospital.  It  is  needless  to  say  that  all 
children  subject  to  fits  should  be  carefully  watched  :  a  public  or  large 
school  is  certainly  not  the  place  for  them,  as  they  require  more  individual 
attention  than  is  possible  under  such  conditions.  There  is  always  the 
possibility  that  they  may  fall  into  the  fire,  or  into  water,  or  be  suffocated 
in  bed  by  a  fit  occurring  during  the  night.  The  state  of  the  bowels  should 
be  most  carefully  attended  to,  as  there  can  be  no  question  that  constipated 
bowels  predispose  to  the  attacks.  Effervescing  citrate  of  potash,  magnesia, 
or  cascara,  with  occasional  small  doses  of  calomel,  are  useful.  Of  all  medicines 
which  check  the  tendency  to  fits  the  bromides  take  first  place.  Bromide  of 
potassium  or  sodium  maybe  given  in  doses  of  10 to  40  grains  a  day,  according 
to  age  and  to  the  frequency  of  the  fits.  The  saline  taste  is  readily  covered 
by  well  diluting  with  water,  and  adding  syrup  of  orange  peel,  aromatic  sp.  of 
ammonia,  or  liq.  ext.  of  Hquorice.     (F.  85,  86,  87.) 

Sometimes  a  laxative  may  be  combined  with  the  bromide  to  counteract 
its  constipating  action  :  sulphate  of  magnesia,  tincture  or  infusion  of  rhu- 
barb, or  'cascara  cordial'  or  'elixir,'  may  be  used,  but,  as  a  laxative  can  be 
given  as  required,  it  is  usually  unnecessary  to  combine  one  with  the  bromide. 
The  bromide  should  be  administered  for  a  month  at  least  after  the  fits,  and 
then  may  be  reduced  in  quantity  ;  but  it  will  be  well  to  continue  the  use  of 
bromide  in  gradually  smaller  doses  for  six  months  at  least  after  the  last  fit  ; 
it  may  be  combined  with  digitalis  or  tonics,  such  as  cinchona,  iron,  or  nux 
vomica. 

Large  doses  of  bromide  give  rise  to  a  lethargic  heavy  condition  in  the 
patient  ;  there  may  be  slow  drawling  speech,  and  a  slow  circulation.  Acne 
is  apt  to  make  its  appearance  after  a  few  doses  of  bromide  in  some 
patients. 

There  is  no  other  drug  that  at  all  approaches  bromide  in  value  for  epilepsy. 
Nitrite  of  sodium,  belladonna,  zinc  oxide  or  lactate  {\  to  5  grs.),  borax  '5  to 
10  grs.),  nitro-glycerine  (o^utOi^Tj  of  a  grain),  and  strjxhnine  have  all  been 
used  with  more  or  less  advantage  when  bromide  fails. 

The  question  of  surgical  interference  must  depend  upon  the  diagnosis  ; 
in  idiopathic  epilepsy  trephining  or  ligature  of  the  carotids  is  hardly  justi- 
fiable. If  there  is  reason  to  believe  that  a  tumour  in  the  cortex  exists,  an 
operation  may  be  considered  (see  p.  499). 

M  M  2 


532  Diseases  of  the  Nervous  System 

Infantile  Convulsions.  XSclampsia. —  Infancy  predisposes  to  those 
irregaUar  nerve  discharges  which  go  by  the  name  of  '  convulsions '  or 
eclampsia.  The  undeveloped  state  of  the  cortical  centres  during  infancy, 
and  the  consequent  absence  or  imperfection  of  the  controlling  or  inhibitory 
influences  exercised  by  these  centres  in  later  life,  allow  the  '  lower  grade ' 
centres  to  discharge  their  stored  nervous  force,  when  stimulated,  in  a  way 
which  does  not  occur  in  later  years.  The  reflex  actions  exhibited  by  the 
brainless  frog  are  more  easily  provoked  and  more  vigorous  than  the  reflex 
actions  exhibited  by  a  frog  with  the  brain  intact ;  the  higher  centres  appear- 
ing to  exercise  a  controlling  influence. 

While  infancy  is  the  time  of  life  in  which  convulsions  are  most  easily 
provoked,  yet  healthy  infants  do  not  become  convulsed  unless  the  stimulus 
is  strong  ;  it  is  the  dehcate  ones  who  are  most  likely  to  suffer,  and  especially 
those  who  have  inherited  neurotic  tendencies.  That  hereditary  influences 
play  an  important  part  there  can  hardly  be  a  doubt,  the  infants  of  those  who 
have  suffered  from  epilepsy  or  who  are  of  a  highly  nervous  disposition 
certainly  more  often  suffer  from  reflex  convulsions  than  do  the  children  of 
strong,  healthy  parents.  The  commonest  predisposing  cause,  however,  is 
rickets,  though  in  what  way  it  acts  is  uncertain  ;  yet  it  is  certain  that  all  the 
tissues  in  rickets  are  badly  nourished  and  built  up,  and  the  nervous  system 
is  no  exception  to  this  :  the  nerve  centres  appear  to  be  in  a  condition  of 
unstable  equilibrium,  and  are  apt  to  discharge  their  nervous  force  in  a  pur- 
poseless and  irregular  manner.  Very  probably  some  toxine  is  formed  in  the 
alimentary  canal,  which  produces  a  sensitive  state  of  the  nervous  centres. 
In  the  large  majority  of  children  who  suffer  from  convulsions  between  the 
ages  of  six  months  and  three  years  the  signs  of  rickets  are  present.  An 
anaemic  condition,  great  exhaustion  from  any  cause,  as  well  as  hereditary 
tendencies,  predispose  to  convulsions  during  the  whole  period  of  childhood, 
but  miore  especially  during  the  first  few  months  of  life. 

The  exciti7ig  causes  of  convulsions  are  mostly  reflex  :  the  irritation  takes 
place  at  some  distant  part,  the  stimulus  passes  up  to  the  nerve  centre  along- 
some  afferent  nerve,  giving  rise  to  a  discharge  from  a  nerve  centre  or 
centres,  the  impulse  travelling  along  the  efferent  nerves  to  the  muscles. 

Reflex  convulsions  may  be  said  to  be  disorderly  physiological  reflex  acts. 
In  a  normal  reflex  act  the  nervous  mechanism  is  properly  controlled  and  a 
useful  movement  takes  place  :  in  a  convulsion  there  is  an  irregular  and 
wasteful  discharge  of  nerve  force  which  fulfils  no  useful  end.  An  infant's 
movements  consist  almost  entirely  of  reflex  acts  of  the  simplest  character, 
the  nerve  centres  in  action  being  of  the  '  lower  grade '  group,  situated  in  the 
spinal  cord,  medulla,  and  pons  :  such  are  the  acts  of  swallowing,  sucking, 
crying,  breathing  ;  in  each  case  there  is  some  form  of  irritation,  or  a  stimulus 
acting  on  the  nerve  centre  and  transmitted  to  it  by  an  afferent  nerve,  and  an 
impulse  is  sent  along  an  efferent  nerve  to  a  muscle  or  group  of  muscles,  and 
a  definite,  perhaps  complex,  act  is  performed.  In  morbid  states  of  the  nerve 
centres  an  afferent  impulse,  calls  forth  a  series  of  irregular  and  muscular  move- 
ments, mostly  in  the  form  of  clonic  spasms,  which  may  be  limited  to  one 
group  of  muscles,  or  may  implicate  almost  all  the  voluntary  muscles  in  the 
body.  Thus  the  presence  of  undigested  curd  in  the  stomach  or  bowels  gives 
rise  to  acute  pain  or  griping,  and  acts  as  a  stimulus  over  a  wide  area,  and 


Infantile  Convulsions  533 

some  distant  nerve  centre,  or  perhaps  many  nerve  centres,  are  thrown  into 
activity.  As  a  consequence  of  this  the  facial  muscles  may  twitch,  the  legs 
be  drawn  up,  the  eyes  roll  about,  the  fingers  be  clenched  ;  there  may  be 
spasm  of  the  respiratory  muscles,  and  all  the  muscles  of  the  extremities  may 
be  thrown  into  clonic  spasm  ;  or  the  infant  suffers  from  whooping  cough,  and 
the  spasm  of  the  glottis- passes  into  a  general  convulsion.  Possibly  the  res- 
piratory muscles  only  may  be  involved,  and  spasm  of  the  glottis  and  of  the 
respiratory  muscles  may  result.  Dyspepsia  or  the  presence  of  indigestible 
food  is  a  fertile  source  of  infantile  convulsions  in  the  newly  born  ;  newly  born 
infants  when  fed  on  artificial  food  frequently  suffer  from  convulsions,  which 
disappear  at  once  when  a  wet-nurse  is  obtained.  In  making  post-mortems 
on  infants  and  young  children  who  have  died  in  convulsions  it  is  no  uncommon 
thing  to  find  an  overloaded  stomach,  and  possibly  pieces  of  meat  and  other 
indigestible  food  in  the  stomach. 

Dentition  is  another  cause  :  the  pressure  of  the  advancing  tooth  upon  the 
gum,  or  the  tension  of  the  tooth  in  its  socket,  may,  through  the  branches  of 
the  fifth  nerve,  produce  g'eneral  convulsions.  Bronchitis  or  pneumonia  may 
be  the  exciting  cause,  though  the  latter  sometimes  produces  convulsions  in 
conseciuence  of  the  high  fever  that  is  present. 

The  exciting  cause  of  the  convulsions  may  act  directly  on  the  centres 
themselves.  Thus  the  onset  of  meningitis  or  any  part  of  its  course  may  be 
marked  by  convulsions  ;  an  infant  has  a  series  of  convulsions  which  are 
perhaps  more  or  less  one-sided,  and  when  they  cease  it  is  noticed  to  be 
hemiplegic,  due,  as  we  have  already  explained,  to  cerebral  haemorrhage  (see 
Cerebral  Hcemorrhage).  The  acute  stage  of  infantile  paralysis  may  be 
attended  with  convulsions.  Convulsions  may  be  caused  by  chronic  brain 
disease.  A  poisoned  condition  of  blood  may  be  the  exciting  cause  ;  thus  a 
temperature  of  104°  or  105°  is  exceedingly  likely  to  be  accompanied  by  con- 
vulsions, the  convulsions  ceasing  when  the  temperature  falls,  and  being 
perhaps  repeated  when  it  rises  again.  Heat-convulsions  are  exceedingly  apt 
to  be  fatal.  A  hypervenous  condition  of  blood  excites  convulsions,  as  seen  in 
infants  born  in  a  condition  of  asphyxia.  The  onset  of  some  zymotic  disease, 
as  scarlet  fever,  measles,  or  influenza,  is  sometimes  marked  by  convulsions. 

Symptoms. — The  convulsive  attacks  vary  greatly  in  their  severity,  and  in 
the  extent  of  the  muscles  involved.  They  may  simply  be  slight  jerky  move- 
ments of  the  head  and  neck,  or  a  limb,  or  there  may  be  slight  twitchings  of 
the  muscles  of  the  mouth  or  eyelids.  The  fingers  may  jerk  and  the  thumbs 
turn  in,  the  toes  become  flexed,  movements  to  which  the  name  of  carpo-pedal 
contractions  has  been  applied.  Such  slight  convulsions  are  often  spoken  of 
by  nurses  and  parents  as  '  inward  fits  ; '  they  are  most  common  in  young 
babies  with  dyspepsia,  or  those  who  are  suffering  from  distended  bowels. 

A  typical  convulsion  closely  resembles  an  epileptic  fit,  but  the  stage  of 
tonic  spasm  is  usually  shorter,  while  the  clonic  spasms  or  muscular  twitch- 
ings are  more  prolonged  and  vigorous.  The  commencement  of  a  fit  is 
frequently  marked  by  a  spasm  of  the  glottis,  so  that  the  nurse  thinks  for  the 
moment  the  infant  is  choking  ;  at  other  times  the  rolling  upwards  of  the 
eyeballs  and  twitchings  of  the  facial  muscles  first  call  attention  to  the  child. 
The  face  becomes  pallid,  the  eyes  are  turned  up  so  as  to  show  '  the  whites,' 
the  limbs  are  e.xtended  and  stiftened,  the  hands  are  clenched,  the  neck  and 


534  Diseases  of  the  NervoiLS  System 

back  are  arched,  the  jaw  closes  spasmodically ;  in  a  few  moments  the  lips 
and  face  become  of  a  bluish  tinge  from  the  respiratory  spasm  ;  the  tonic 
spasm  quickly  passes  into  clonic,  the  hands,  feet,  and  face  '  work '  for  a  few 
seconds  or  more,  and  the  child  becomes  quiescent  and  the  fit  is  over.  The 
child  becomes  unconscious  during  the  fit,  and  may  remain  dazed  for  a  few 
minutes  to  half  an  hour  after. 

The  fits  may  be  severe,  much  of  the  type  of  a  major  epileptic  fit,  the 
tongue  being  held  tightly  between  the  gums  or  injured  by  the  teeth,  the  child 
frothing"  at  the  mouth  and  becoming  cyanosed,  and  remaining  comatose  or 
drowsy  for  some  time.  On  the  other  hand,  the  convulsions  may  be  partial 
only  :  one  side  may  be  affected,  the  leg,  arm,  and  side  of  the  face  twitching, 
or  the  laryngeal  muscles  or  respiratory  muscles  alone  may  suffer.  The  fre- 
quency with  which  fits  occur  differs  very  much  :  a  child  may  have  a  single 
one,  and  it  may  never  be  repeated  ;  or  they  may  recur  daily,  or  there  may 
be  a  constant  succession  of  fits  for  twenty-four  or  forty-eight  hours,  the  child 
never  becoming  conscious.  Some  of  the  most  severe  convulsions  we  have 
ever  witnessed  have  been  in  connection  with  whooping  cough.  The  child 
begins  to  cough  and  forthwith  a  general  spasm  of  the  respiratory  muscles 
takes  place,  with  spasm  perhaps  of  the  muscles  of  the  limbs.  The  child 
becomes  dusky  or  pallid,  and  appears  to  be  dead.  Perhaps  by  the  aid  of 
artificial  respiration  it  comes  round,  but  such  attacks  are,  we  need  not  say, 
exceedingly  fatal. 

Death  may  take  place  in  the  fit  from  spasm  of  the  glottis.  In  other 
cases  death  seems  to  be  caused  in  some  way  through  the  nervous  system,  as 
after  death  no  evidence  of  asphyxia  can  be  found.  Convulsions  in  older 
children  are  indistinguishable  from  epileptic  fits,  and  doubtless  many  of  such 
cases  for  which  no  cause  is  found  are  really  epileptic,  or  at  any  rate  showing 
a  tendency  in  that  direction. 

Con-\'ulsions  may  be  associated  with  idiocy  or  some  mental  defect,  and 
it  is  not  always  easy  to  say  to  what  extent  the  convulsions  depend  upon  the 
presence  of  some  cerebral  lesion  or  malformation,  or  whether  the  mental 
defect  is  produced  by  the  fi'equently  recurring  fits.  It  is  not  uncommon  to 
see  children  of  a  few  months  to  a  year  old  who  are  frequently  convulsed, 
and  who  are  evidently  idiots,  not  able  to  sit  up  or  hold  anything  in  their 
hands,  and  not  recognising  their  friends.  In  these  cases  the  prognosis,  as 
far  as  the  mental  development  is  concerned,  is  grave,  though  the  fits  often 
become  less  frequent  or  cease  as  the  infant  develops. 

Prognosis. — This  must  always  be  uncertain,  and  naturally  depends  upon  the 
exciting  causes.  The  first  fit  may  prove  fatal  through  spasm  of  the  glottis  ; 
on  the  other  hand,  it  is  common  to  get  a  history  of  children  who  as  infants 
were  constantly  convulsed  and  yet  have  grown  into  comparatively  strong 
children.  Naturally  much  must  depend  upon  what  the  exciting  cause  of  the 
fit  is  :  if  it  suggest  commencing  meningitis  the  prognosis  is  necessarily  bad  ; 
if  there  is  hyperpyrexia  and  commencing  pneumonia  it  is  very  grave.  Con- 
vulsions following  on  some  exhausting  disease,  as  diarrhoea,  are  mostly  fatal. 
Convulsions  associated  with  laryngismus  are  always  serious,  and  the  prognosis 
must  be  very  guarded.  In  those  cases  where  the  fits  in  young  infants  are 
frequently  repeated,  it  must  be  borne  in  mind  that  they  may  prove  to  be 
epileptic  or  associated  with  mental  deficiency,  and  a  guarded  prognosis  must 


Infantile  Convulsions  535 

be  given.  If  there  is  reason  to  believe  that  the  convulsions  are  due  to 
dyspepsia  or  are  symptomatic  of  rickets,  the  prognosis  as  far  as  the  cerebral 
development  of  the  child  is  concerned  is  good,  but  there  is  always  the  risk 
of  its  dying  in  a  fit. 

Diagnosis. — The  exciting  cause  of  the  convulsions  may  be  difficult  or 
impossible  to  determine.  Convulsions  in  infants  shortly  after  birth  may  be 
due  to  a  hypervenous  state  of  the  blood  I'esulting  from  congenital  heart 
disease  or  atelectasis,  or  to  a  meningeal  haemorrhage,  which  has  taken 
place  during  birth.  If  these  can  be  excluded  there  is  a  strong  probability  that 
the  fits  are  due  to  some  digestive  disturbance,  especially  if  the  infant  is  being 
artificially  nursed.  In  infants  over  six  months  of  age,  with  the  symptoms  of 
rickets,  the  fits  are  in  all  probability  reflex  and  clue  to  some  alimentary 
troubles  such  as  flatulence,  or  griping  in  order  to  expel  undigested  curd  ;  but 
the  possibility  of  their  being  due  to  commencing  meningitis  or  to  the  presence 
of  tubercles  in  the  brain  must  always  be  borne  in  mind,  even  in  the  case  of  fat, 
healthy-looking  infants.  Vomiting,  irregularity  or  hesitation  of  the  pulse- 
beat,  or  an  unnatural  softness  of  the  abdomen  would  suggest  meningitis. 
The  possibility  of  the  convulsions  in  infants  being  followed  by  a  hemiplegia 
or  a  paralysis  of  one  or  more  limbs  must  not  be  forgotten.  In  convulsions 
in  young  children  the  chest  should  be  carefully  examined  and  the  tempera- 
ture taken,  and  the  skin  inspected  to  ascertain  the  presence  or  absence  of  a 
rash.  In  frequently  recurring  fits  there  is  a  possibility  that  the  child  may 
grow  up  mentally  deficient,  and  a  careful  inquiry  should  be  made  as  to  the 
child's  intelligence. 

The  fact  that  infants  often  suffer  from  one-sided  convulsions,  or  that  the 
convulsion  begins  on  one  side,  must  not  be  taken  to  indicate  that  there  is  brain 
disease  of  the  opposite  side,  inasmuch  as  reflex  convulsions  due  to  intestinal 
irritation  may  be  one-sided  in  the  first  instance. 

Morbid  Anatomy. — Convulsions  per  se  leave  no  trace  in  the  dead  body, 
though  usually  there  are  the  signs  of  death  from  asphyxia,  the  latter  being 
most  marked  in  those  dying  suddenly  in  strong  health.  The  veins  on  the 
surface  of  the  brain  are  full  of  dark  blood,  there  are  punctiform  or  larger 
haemorrhages,  and  the  brain  may  be  unusually  full  of  blood  and  wet  from 
excess  of  cerebro-spinal  fluid  on  the  surface  and  in  the  lateral  ventricles,  but 
these  conditions  are  due  to  death  taking  place  through  stasis  of  blood  in  the 
lungs  and  a  consequent  engorgement  of  the  general  venous  system.  The 
post-mortem  examination  of  the  state  of  the  cerebral  vessels  gives  us  no  clue  to 
their  condition,  whether  of  engorgement  or  anaemia,  during  the  fit  itself,  except 
such  as  are  produced  by  venous  obstruction.  In  many  cases  the  autopsy 
throws  no  light  on  either  :  the  cause  of  the  fit  or  the  conditions  which 
accompanied  the  fit.  In  others  the  appearances  of  commencing  bronchitis 
or  pneumonia  or  acute  intestinal  catarrh  may  be  found.  Difficulties  are, 
however,  likely  to  be  met  with  at  \k\<t  post-mortem  in  distinguishing  between 
early  pneumonia  and  the  sodden  and  oedematous  lung-  often  present  which 
is  due  to  the  manner  of  death — namely,  asphyxia  from  obstruction  to  the 
entrance  of  air  into  the  larynx. 

In  making  an  examination  for  medico-legal  inquiries  as  to  the  cause  of 
death,  whether  from  a  convulsion  or  from  some  other  cause,  great  caution 
must  be  exercised  in  coming  to  a  conclusion,  especially  in  infants.    An  infant 


536  Diseases  of  the  Nervous  System 

may  have  been  '  overlain,'  i.e.  suffocated  beneath  the  bedclothes  in  conse- 
quence of  the  mother  going  to  sleep  with  the  infant  at  the  breast,  the  mother 
perhaps  alleging  that  the  infant  had  died  in  a  fit.  In  both  cases  the  after- 
death  appearances  may  perhaps  be  much  alike — namely,  those  of  death  from 
asphyxia.  In  many  cases,  however,  a  distinction  may  be  made  between  a 
rapidly  produced  asphyxia  as  in  death  from  a  fit,  and  a  more  slowly  produced 
asphyxia,  as  in  slow  suffocation  beneath  the  bedclothes  :  in  the  former  the 
lungs  are  simply  gorged  with  dark  fluid  blood,  in  the  latter  case  the  lungs 
are  sodden  and  oedematous,  containing  a  large  amount  of  frothy  fluid.  In 
any  case  where  the  tongue  is  held  between  the  teeth  and  has  been  injured, 
and  there  are  signs  of  rickets,  the  lungs  gorged  with  dark  fluid,  and  the  veins 
on  the  surface  of  the  brain  overfull,  there  is  a  strong  probability  that  the 
child  has  died  in  a  fit.  It  must  not,  however,  be  too  hastily  assumed  that 
a  convulsion  has  not  been  the  cause  of  death,  because  the  typical  signs  of 
asphyxia  are  not  present ;  death  appears  to  take  place  in  some  cases  pro- 
bably through  the  nervous  system,  before  asphyxia  takes  place. 

Treat7nent. — The  treatment  of  convulsions  must  necessarily  be  chiefly 
directed  to  removing  the  cause.  During  the  convulsion  itself,  if  there  is  a 
high  temperature  (104°- 106°),  no  time  should  be  lost  in  placing  the  infant 
or  child  in  a  tepid  bath  and  pouring  cold  water  over  the  child  and  into  the 
bath  in  order  to  lower  the  temperature,  which  is  probably  exciting  the  con- 
vulsions, and  it  may  be  also  necessary  to  give  antifebrin  or  quinine.  In  reflex 
convulsions  in  a  robust  child,  especially  if  there  is  colic  or  abdominal  dis- 
turbance, a  warm  bath,  or  a  mustard  bath  so  as  to  redden  the  skin,  is  likely 
to  prove  of  service,  or  the  child's  socks  may  be  wrung  out  of  mustard  and 
water  and  placed  on  the  feet,  or  hot  flannels  may  be  placed  on  the  abdomen. 
If  there  is  reason  to  suppose  the  convulsions  are  due  to  cerebral  disease, 
or  the  convulsions  come  on  at  the  end  of  an  exhausting"  illness,  the  warm 
bath  is  not  likely  to  be  of  any  service  and  may  be  injurious.  If  the  child 
has  taken  any  indigestible  food,  which  is  lying  in  the  stomach  or  in  the 
bowels,  an  emetic  or  one  or  two  grains  of  calomel  should  be  administered 
according  to  the  effect  desired.  If  the  gums  are  swollen  and  tender,  an 
incision,  or  simply  scarifying  them,  will  often  do  good.  If  there  is  otitis,  it 
may  be  well  to  puncture  the  membrane. 

The  inhalation  of  a  few  drops  of  chloroform  or  nitrite  of  amyl  will 
usually  check  the  violence  of  the  convulsive  spasms,  and  should  certainly 
be  tried  if  the  convulsions  last  any  time  or  are  violent.  Of  medicines 
which  diminish  the  irritability  of  the  nervous  centres,  the  bromides,  chloral, 
and  belladonna  hold  the  first  place.  Bromide  of  potassium  or  sodium  must 
be  given  freely  if  the  convulsions  recur  time  after  time.  If  the  child  can 
swallow,  3  to  5  grains  may  be  given  to  an  infant  of  six  months  to  a  year  old, 
and  repeated  every  hour  or  two  for  several  doses,  according  as  the  convul- 
sions are  present  or  not ;  smaller  doses,  less  often  repeated,  should  be  given 
if  improvement  takes  place.  No  harm  is  likely  to  ensue  by  pushing  the 
bromide.  The  bromide  may  be  given  by  the  rectum  if  necessary.  Chloral 
is  in  some  cases  more  useful  than  bromide,  but  it  must  be  used  more 
sparingly  ;  a  two-  or  three-grain  dose  may  be  given  to  an  infant  under  a  year, 
and  repeated  in  an  hour  if  the  convulsions  are  still  present,  but  its  soporific 
effect  must  be  watched.     Chloral,  we  are  inclined  to  think,  is  more  useful 


Tetany  537 

than  bromide  in  convulsions  due  to  colic  or  whoopini^"  cough.  Bromide, 
choral,  and  cannabis  indica  are  often  given  in  combination  with  advantage 
in  convulsions.  (F.  88,  89,  90.)  Cold  to  the  head  in  the  form  of  ice  or  wet 
cloths  should  be  used  if  meningitis  is  suspected,  and  the  infant  should 
be  carefully  protected  from  all  excitement. 

Convulsions  in  infants  a  few  weeks  old,  who  are  artificially  fed,  are  due 
in  the  large  majority  of  cases  to  dyspepsia,  and  no  time  should  be  lost  in 
procuring  a  wet-nurse,  or  at  any  rate  in  giving  the  infant  the  most  suitable 
food  that  can  be  procured.  The  bromides  will  have  but  little  effect  in  stop- 
ping the  convulsions  as  long  as  acute  dyspepsia  or  colic  is  present. 

Tetany 

The  term  'tetany'  is  applied  to  a  form  of  tonic  spasm  mostly  affecting 
the  extremities,  which,  like  spasm  of  the  glottis,  consists  in  a  reflex  con- 
traction of  a  group  of  muscles,  the  result  of  irritation  in  some  distant 
part.     Tetany  may  affect  both  children  and  adults,  though  it  is  commoner 


Fig.  113. — Tetany  affecting  limbs,  also  muscles  of  neck. 

before  the  age  of  three  years  than  after  this  period.  It  is  frequently  asso- 
ciated with  rickets,  in  this  respect  resembling  convulsions  and  laryngeal 
spasm  ;  it  frequently  occurs  in  connection  with  laryngismus.  It  rarely 
makes  its  appearance  in  healthy  children,  but  in  those  who  have  suffered 
from  some  exhausting"  disease,  especially  some  affection  of  the  alimentary 
canal,  as  diarrhoea  or  acute  enteritis  ;  prolapse  of  the  rectum  may  be  an 
exciting"  cause.  Difficult  dentition  appears  to  be  an  occasional  cause.  One 
of  the  most  severe  cases  we  have  seen  was  associated  with  a  fatal  attack  of 
acute  enteritis.  It  has  been  observed  in  rare  instances  as  an  early  symptom 
in  pneumonia  and  other  diseases,  in  this  respect  resembling  convulsions, 
and  tonic  contraction  of  the  muscles  at  the  back  of  the  neck.  It  has  some- 
times prevailed  epidemically  among  school-girls,  but  in  such  cases  the 
muscular  contractions  were  no  doubt  due  to  hysteria. 

Symptoms  and  Coicrse. — The  attacks  consist  in  spasms  of  the  muscles  of 
the  extremities,  more  especially  of  the  forearms  and  feet.  There  is  no  loss 
of  consciousness,  and  usually  no  spasm  of  the  facial  muscles,  though  there 
is  mostly  an  expression  of  pain  on  the  face  when  the  cramps  come  on.  In 
the  severer  cases  the  arm  is  adducted  at  the  shoulder  and  fixed  to  the  side, 


538 


Diseases  of  the  Nervotis  System 


the  elbow  is  flexed  at  right  angles,  the  forearm  pronated,  the  wrist  flexed,  the 
thumb  turned  in,  while  the  fingers  are  in  the  position  of  interosseous  spasm, 
forming  what  is  known  as  the  '  accoucheur's  hand  ; '  in  other  cases  the 
fingers  are  spread  out  (see  fig.  114). 

In  the  lower  extremities  the  foot  is  in  the  position  of  talipes  equinus  or 
equino-varus,  the  plantar  surfaces  being  hollowed  out  and  the  toes  bent. 
The  knees  may  be  semi-flexed  and  the  thighs  adducted.  The  muscles  of 
the  calf  are  hard  and  rigid,  feeling  as  if  gathered  up  into  a  ball.  There  is 
usually  oedema  of  the  doi'sum  of  the  feet  and  hands,  from  interference  with 
the  venous  circulation. 

The  contractions  are  evidently  painful  ;  the  infants  scream  when  they 
are  handled  or  interfered  with  ;  the  spasms  may  intermit,  but  usually  last  a 
considerable  time.     In  rare  cases,  notably  those  recorded  by  Cheadle,  the 

muscles  of  the  face  are  thrown 
into  spasm  ;  in  other  cases  the 
muscles  of  the  jaw,  abdomen, 
neck,  and  back  have  been 
affected  (see  fig.  113).  More 
commonly  the  spasm  is  con- 
fined to  the  hands  and  feet, 
or  the  hands  only  may  be 
affected.  The  spasm  lasts  from 
a  few  minutes  to  many  hours 
or  even  days,  then  disappear- 
ing and  perhaps  appearing" 
again.  Most  of  the  muscles 
of  the  body  ai"e  in  a  condition 
of  irritability,  especially  those 
of  the  face.  This  is  evidenced 
by  the  readiness  with  which 
they  contract  when  the  facial 
nerve  is  irritated.  If  the  finger 
be  passed  smartly  over  the 
angle  of  the  mouth,  a  sharp 
contraction  of  the  levator  fol- 
lows ;  or  the  finger  is  brushed 
across  the  outer  side  of  the 
orbit,  and  a  contraction  of  the 
orbicularis  ensues.  This 'facial 
phenomenon,'  however,  is  not 
peculiar  in  tetany.^  The  same  irritable  condition  of  muscles  can  sometimes 
be  demonstrated  by  compression  of  the  large  nerve  trunks  of  the  arm,  which 
may  give  rise  to  muscular  spasm  in  the  hands  and  fingers.  This  is  sometimes 
referred  to  as  '  Trousseau's  phenomenon.' 

Tetany  never  threatens  life  per  se,  as  it  only  affects  the  muscles  of  external 
relation,  though  the  child  may  die  from  the  effects  of  the  gastro-enteritis, 
of  which  the    muscle  cramps  are  only  symptoms.     The    only  case  which 

1  J.  Loos,  M.D.,  Wiener  klin.  IVochenschr. 'No.  49,  1891  ;  'Laryngismus,'  Dr.  W. 
Gay,  Brain,  January  1890. 


Fig.  114. --Tetany  of  the  hands  and  feet  (from  a 
photograph  by  Dr.  L.  W.  Crowe). 


Tetany— Nystagmus  539 

terminated  fatally,  which  we  have  seen,  was  the  case,  referred  to  above,  of 
a  boy  aged  six  years,  who  died  in  a  few  days  from  the  effects  of  a  gastro- 
enteritis ;  the  principal  symptoms  were  constant  vomiting,  cramps  in  the 
stomach,  and  tetany  of  both  upper  and  lower  extremities.  T\\e.  posf-moriefn 
showed  the  brain  and  cord  to  be  normal  to  the  naked  eye  ;  the  mucous 
membranes,  of  the  stomach  and  intestines  were  injected,  and  evidently  in  a 
state  of  acute  catarrh.  In  another  case,  somewhat  similar,  Hadden  could 
find  no  changes  in  the  cord. 

Tetany  is  apt  to  return  from  time  to  time  after  a  considerable  interval  ; 
this  may  be  noticed  in  cases  received  into  hospital  :  these  mostly  get  well 
quickly  and  go  home,  but  in  another  week  or  two  are  as  bad  as  ever. 

Diagnosis. — Tetany  may  be  mistaken  for  cerebro-spinal  meningitis,  but  it 
can  only  thus  be  mistaken  when  the  constitutional  symptoms  accompanying 
the  tetany  are  severe.  In  tetany  there  is  an  absence  of  cerebral  symptoms 
as  well  as  of  vomiting  and  fever.  In  tetanus  the  spasm  of  the  masseters  is 
an  early  symptom  ;  it  is  absent  in  tetany,  or  comes  on  late  in  the  attack. 
The  position  of  the  fingers  is  different  in  the  two  diseases.  In  girls  or  older 
boys  hysterical  contraction  might  stimulate  tetany,  but  the  former  usually 
affects  one  limb,  or  an  arm  and  a  leg  only,  while  the  latter  is  always  bilateral. 

Treatment. — The  treatment  must  be  directed  in  the  first  place  to  the 
exciting  cause.  A  dose  of  calomel  or  grey  powder  should  be  given  if  there 
is  any  gastro-intestinal  disturbance  or  undigested  food  lodging  in  the 
intestinal  tract,  and  the  greatest  care  taken  to  give  only  the  blandest  food. 
Warm  baths  may  be  given  to  relieve  the  spasm,  and  hot  laudanum  fomen- 
tations applied  to  the  hands  and  feet.  Bromide  of  potassium  is  likely  to 
relieve  the  symptoms  if  given  in  full  doses.  Chloral,  belladonna,  digitalis, 
and  Calabar  bean  have  all  been  used  with  benefit.  Cheadle  found  the  ^ 
to  +  dose  of  Calabar  bean  of  use  in  one  case. 

STystagmus. — Nystagmus  is  common  during  both  infancy  and  childhood 
and  accompanies  very  different  conditions.  It  usually  consists  in  short 
rapid  oscillations  of  the  eyeballs  in  a  lateral  direction,  the  head  sometimes 
moving  also.  In  some  cases  the  ocular  movements  are  vertical  instead  of 
lateral.  Jt  may  be  present  in  congenital  cataract,  tumours  of  the  brain, 
hydrocephalus  and  hereditary  ataxia  ;  but  it  is  also  present  in  children  who 
are  not  suffering  from  any  organic  disease.  It  may  be  present  in  some  forms 
of  clonic  spasm  of  the  neck. 

Head-nodding-  and  Head-shaking,  going  on  constantly  as  they  some- 
times do  in  infants  and  young  children,  are  the  result  of  a  chronic  reflex 
spasm  of  the  sterno-mastoids,  either  both  acting  together  and  making  a 
nodding  movement,  as  in  expressing  assent,  or  acting  alternately  and  shaking 
the  head  as  if  expressing  dissent.  The  movements  may  be  constant  or 
intermittent,  perhaps  ten  or  twelve  times  a  minute.  Nystagmus  may  be 
present.  These  curious  spasmodic  affections  appear  to  be  allied  to  laryn- 
gismus. Dr.  Gee  records  a  case  whose  brother  died  of  laryngismus,  and  in 
one  case  of '  head-nodding '  mentioned  by  A.  Baginsky,  the  child  suffered 
later  from  convulsions  and  laryngismus.  Head-shaking  in  older  children 
Dr.  Gee  connects  with  epilepsy.  The  prognosis  is  good  ;  like  laryngismus, 
these  affections  appear  to  be  due  to  some  reflex  irritation  in  the  alimentary 
canal  or  to  dentition. 


54©  Diseases  of  the  Nervous  System 

'Head-banging'  '  in  children  has  been  described  by  Dr.  S.  Gee.  It  con- 
sists in  a  pecuhar  habit,  to  which  some  children  are  liable,  of  turning  over  on 
to  their  face  at  night  and  banging  their  heads  into  the  pillow.  Dr.  Gee 
records  three  cases  :  two  of  these  were  two  and  a  half  years  of  age,  and  one 
was  five  years.  One  child  used  constantly,  nearly  all  night,  to  bang  his 
forehead  into  his  pillow.  No  cause  was  found  to  account  for  .this  strange 
habit.  It  appeared  very  intractable,  but  one  child  much  improved  whilst 
living  in  the  country. 

Hysteria. — Functional  nerve  disturbances,  in  the  form  of  sensory  de- 
rangements, paresis,  contractures,  or  eclampsia,  are  by  no  means  uncom- 
mon in  children.  Hysteria  when  it  occurs  during  early  life  mostly  affects 
girls,  but  it  occurs  also  in  boys  ;  the  approach  of  puberty  is  the  most  common 
period. 

A  tendency  to  hysteria  runs  in  families,  and  is  transmitted  from  parents 
to  children,  but  the  foolish  way  in  which  children  are  often  brought  up,  their 
weaknesses  pampered  and  their  ailments  intensified  by  injudicious  sympathy, 
often  tends  to  aggravate  an  hereditary  disposition  to  nerve  disorders. 
While  it  most  frequently  happens  that  hysterical  children  come  of  neurotic 
families  and  belong  to  the  well-to-do  classes,  yet  such  children  may  be 
found  in  country  districts  among  country  folk,  where  neurotic  tendencies 
might  be  least  expected.  '  Fasting  girls '  who  have  had  a  temporary  notoriety, 
'  cataleptics,'  and  religious  maniacs  have  been  found  in  cottage  homes  and 
among  surroundmgs  that  one  would  have  supposed  were  little  likely  to  foster 
hysterical  affections. 

Hysteria  in  its  milder  or  severer  forms  is  often  associated  with  other 
diseases,  such  as  epilepsy,  chorea,  and  various  mental  affections  ;  it  may  also 
be  engrafted  on  to  organic  brain  disease,  such  as  meningitis  or.  some  spinal 
affections.  Hysterical  phenomena  are  rare  before  the  age  of  six  years  and  are 
most  common  about  puberty,  especially  in  those  cases  where  menstruation 
has  failed  to  become  established. 

Symptonis.  Seitsory  Disturbances. — Perhaps  the  most  common  form 
of  hysteria  in  girls  is  hyperEesthesia  ;  there  is  a  complaint  of  tenderness 
or  pain  which  cannot  be  accounted  for  except  by  a  neurosis.  There  is  some 
local  tenderness  about  the  spine  or  one  of  the  joints,  especially  the  hip,  the 
girl  screaming  with  pain  when  the  joint  is  moved  ;  the  thyroid  gland  or 
front  of  the  larynx  is  sornetimes  hypersensitive.  Headaches  are  very  common  : 
these  may  be  frontal  or  occipital,  or  may  take  the  form  of  the  '  clavus '  of 
adults.  Hysteria  is  apt  to  mimic  various  diseases  which  are  normally 
accompanied  by  severe  pain,  such  as  peritonitis,  pleurisy,  rheumatism  ;  it 
must,  however,  be  always  borne  in  mind  that  there  may  be  some  actual 
disease  present,  and  that  the  sensory  disturbance  is  only  an  exaggerated 
condition  of  what  would  normally  exist. 

Anaesthesia  is  much  less  common  in  children  than  hyperjesthesia  ;  but 
hysterical  hemianaesthesia,  in  which  the  special  senses  are  involved,  occa- 
sionally occurs.  Sleeplessness  is  not  uncommon,  the  patients  asserting  that 
they  cannot  sleep,  and  only  perhaps  dozing  off  when  it  is  time  to  get  up. 

Motor  Distii-rbances. — Paralysis,  or  rather  paresis,  is  common  ;  the  larynx 
is  perhaps  most  frequently  affected,  but  paraplegia  is  not  infrequent.  Hys- 
terical aphonia  in  girls  has  the  same  characters  as  in  adults  :  there  is  loss 


Hysteria 


541 


of  voice,  the  patient  always  speaking  in  a  whisper  ;  sometimes  the  voice  is 
entirely  lost. 

Paraplegia  may  come  on  suddenly  after  a  convulsion,  or  the  legs  may 
gradually  give  way  under  the  child,  until  she  can  no  longer  stand,  and  is 
therefore  confined  to  bed.  There  may  be  loss  of  sensation,  but  in  our 
experience  this  is  uncommon.  The  loss  of  power  is  never  complete  :  the 
patient  moves  the  legs  in  bed,  and  often  some  attempt  will  be  made  to 
stand  with  help,  or  she  may  draw  up  the  legs  to  prevent  them  touching  the 
ground,  and  will  sink  to  the  ground  rather  than  support  her  own  weight. 
The  electrical  reactions  are  normal, 
and  usually  the  knee-jerk  is  also 
normal,  and  there  is  no  ankle- 
clonus.  In  other  cases,  more 
especially  those  which  have  lasted 
some  time,  there  is  more  or  less 
tonic  contracture  of  the  legs  ;  the 
hip  and  knee  joints  are  semi- 
flexed, and  the  foot  takes  the 
position  of  equino-vainis.  In  this 
condition,  if  the  spasmodic  con- 
traction is  not  too  marked,  there 
may  be  excessive  knee-reflex,  and 
ankle-clonus  may  be  present  ;  if 
there  is  marked  contracture,  no 
knee-reflex  can  be  obtained  on 
account  of  the  rigid  contracture  of 
the  opposing  muscles.  The  con- 
tracture is  present  during  sleep, 
but  usually  goes  off  when  the 
patient  is  under  chloroform. 

Hemiplegia  is  perhaps  less 
common.  In  one  of  our  patients, 
a  girl  £et.  seven  years,  there  was 
a  history  of  a  fright  from  a  cat 
jumping  on  her  bed  ;  immediately 
after  the  right  arm  and  leg  were 
affected.  The  elbow  became  bent, 
the  wrist  flexed  and  fingers  bent 
over  the  thumb  ;  the  right  leg  was 

similarly  affected,  but  in  less  degree.  The  flexor  muscles  were  in  a  constant 
state  of  spasm,  except  during  sleep,  when  they  were  relaxed  (see  fig.  115)- 
When  the  girl's  attention  was  directed  awa}^  from  herself,  she  would  use 
the  arm  to  some  extent,  raising  her  hand  to  her  mouth  or  head. 

In  hysterical  paraplegia  there  is  no  incontinence  of  urine  or  fsces  ;  this 
is  certainly  the  z-ule,  but  retention  of  urine  will  occur,  and  in  some  conditions, 
such  as  '  hysterical  chorea,'  both  urine  and  faeces  will  at  times  be  passed 
involuntarily.  We  have  seen  on  various  occasions  girls  who  were  suffering 
from  hysteria,  simulating  hip  disease  or  peritonitis,  pass  their  water  in 
bed,  so  that  the  bed  and  linen  have  been  saturated  with  stinking  urine,  rather 


J'ig.  115. — Hysterical  Spastic  Hemiplegia. 


542  Diseases  of  the  Nervous  System 

than  use  a  bed-pan,  as  they  were  afraid  of  being  moved  on  account  of  the 
pain  it  caused.  In  such  cases  bedsores  may  form  and  the  patient  become 
emaciated. 

Convulsive  Attacks. — These  are  of  the  usual  hysterical  type.  There 
is  a  fit  of  screaming  or  crying  or  violent  laughter,  tonic  contraction  of  the 
muscles,  more  especially  of  the  back,  so  that  opisthotonos  is  produced  ;  the 
arms  and  legs  are  dashed  about,  and  the  head  perhaps  made  to  strike  the 
pillow  or  bed  violently.  The  patient  remains  conscious  during  the  attack, 
and  she  rarely  injures  herself,  and  the  tongue  is  not  bitten.  The  so-called 
'  hysteroid '  fits  have  already  been  referred  to  (p.  528). 

Mental  Symptoms. — Hysteria  is  closely  allied  to  some  forms  of  insanity, 
and  various  forms  of  hysterical  insanity  occur  in  girls  about  puberty.  One 
of  the  commonest  of  these  is  a  refusal  of  food.  The  girl's  appetite  becomes 
poor,  she  gradually  grows  thin,  and  this  excites  the  sympathy  and  alarm  of 
her  friends.  The  morbid  craving  for  sympathy  becomes  intensified.  She 
resists  all  their  entreaties  to  take  food,  and  clenches  her  teeth  when  it  is 
offered,  or  only  takes  the  smallest  quantities,  and  frequently  is  guilty  of 
deceit,  concealing  food  in  her  clothes.  She  gradually  wastes  till  she  becomes 
a  perfect  skeleton,  the  skin  is  rough  and  harsh,  the  abdomen  flattened,  and 
the  breath  foul.  Bedsores  not  infrequently  form.  In  other  cases,  though  re- 
fusing all  food  at  meal  times,  she  will  surreptitiously  obtain  cakes  or  confec- 
tionery, which  she  will  eat  readily.  In  some  of  these  cases  there  is  melan- 
cholia or  eclampsia.  Morbid  conscientiousness  is  sometimes  present ;  the 
girl  perhaps  takes  away  marks  from  herself  at  school,  or  accuses  herself  of 
having  told  untruths  or  of  having  stolen  her  schoolfellows'  things. 

Vomiting  and  spasm  of  the  pharynx  are  not  uncommon  ;  one  or  other 
of  these  may  be  present  for  months  and  lead  to  wasting'.  Usually  the  food 
returns  at  once  or  within  a  few  minutes  of  taking.  Sometimes  the  food  will 
be  retained,  but  there  is  nausea  and  retching. 

Diagjiosis. — The  first  step  in  diagnosis  is  necessarily  to  attempt  to  exclude 
organic  disease,  which  hysteria  so  often  mimics.  In  sensory  hysterical  dis- 
orders, such  as  headaches,  and  in  various  forms  of  paralysis,  the  question 
is  whether  or  not  there  is  cerebral  or  spinal  disease.  Probably  the  com- 
monest mistake  is  to  assume  that  organic  disease  exists  when  the  condi- 
tion is  one  of  hysteria  only ;  but,  on  the  other  hand,  we  have  known  the 
symptoms  in  the  early  stages  of  a  cerebral  tumour  attributed  to  hysteria.  It 
is  often  necessary  to  wait  before  a  definite  diagnosis  can  be  arrived  at.  But 
it  is  always  necessary  to  bear  in  mind  that  an  organic  lesion  may  exist  and 
yet  undoubted  hysterical  symptoms  be  present. 

Treatment. — The  treatment  of  hysteria  in  its  various  forms  is  principally 
moral.  The  management  of  the  patient  must  pass  from  the  parents  to  a 
suitable  nurse,  or,  better  still,  the  patient  should  be  removed  to  hospital  or  into 
lodgings  away  from  her  fi-iends.  If  once  the  child  is  under  firm  control,  is 
■deprived  of  the  morbid  sympathy  it  craves  for,  and  is  at  the  same  time  en- 
couraged to  put  forth  all  its  voluntary  power,  an  improvement  in  its  condition 
will  immediately  begin.  In  cases  of  paralysis,  in  addition  to  isolation  from 
the  parents  and  all  sympathising  friends,  massage  and  faradisation  are  of 
much  advantage.  The  patient  must  be  made  to  use  the  weakened  limbs  in 
moderation,  and  encouraged  to  believe  that  they  will  get  entirely  well. 


Headaches  543 

In  less  severe  cases  change  from  city  to  a  healthy  country  life  is  of  great 
importance.  Life  at  a  farm  with  its  many  outdoor  attractions  and  occupa- 
tions is  perhaps  the  best  adapted  for  hysterical  children.  Effort  must  be 
made  to  interest  them  in  many  things  outside  themselves  in  order  to  break 
the  vicious  habit  of  dwelling  inordinately  on  their  own  feelings  and  ailments. 
In  many  of  these  cases  the  general  health  is  poor  and  menstruation  delayed. 
In  such,  iron  in  the  form  of  bromide  of  iron,  as  in  Fletcher's  syrup,  is  useful, 
while  the  bowels  should  be  regularly  acted  on  by  small  doses  of  aloes,  or  some 
mineral  water  such  as  Rubinat  or  Hunyadi  Janos. 

Headaches. — Children,  especially  girls  of  seven  years  of  age  on  to 
puberty,  are  very  liable  to  headaches,  sufficiently  severe  to  lay  them  up  for 
part  of  a  day  or  perhaps  longer.  These  headaches  may  arise  from  various 
causes,  and  it  is  important  to  try,  if  possible,  and  ascertain  their  origin  ; 
diagnosis  is  frequently  by  no  means  easy,  as  pain  is  referred  to  the  forehead 
in  many  different  morbid  states  and  conditions.  Frontal  headache  is  by  far 
the  commonest  form  of  reflected  pain.  It  is  important  in  the  first  place  to 
exclude  hypermetropia  as  a  cause  of  frontal  headache.  Straining  the  accom- 
modation of  the  eyes,  especially  when  the  subject  is  below  par,  may  give  rise 
to  frontal  headache,  aching  being  referred  to  the  eyeballs,  while  at  the  same 
time,  when  an  attempt  is  made  to  read,  the  letters  run  together  and  the 
eyes  easily  water.  A  diagnosis  is  easily  made  with  the  ophthalmoscope, 
examining  the  retinal  vessels  by  the  direct  method,  as  well  as  by  the  use  of 
test  types. 

Headaches  are  very  common  in  rapidly  growing  children,  who  are,  to 
use  an  ordinary  expression,  '  outgrowing'  their  strength.'  Such  headaches 
may  be  due  merely  to  weariness  or  to  the  irritable  state  of  the  nerves  which 
comes  on  when  o\'er-tired  or  fagged  ;  or  they  may  be  due  to  anaemia  or 
dyspepsia.  The  latter  is  probably  the  most  frequent  cause.  The  appetite 
may  be  good  or  capricious,  more  food  is  taken  than  the  digestive  organs  can 
cope  with,  and  dyspepsia  or  a  subacute  gastric  or  intestinal  catarrh  is  the 
result.  A  sick  headache  is  complained  of,  the  child  looks  heavy  and  dark 
about  the  eyes,  there  is  nausea  or  actual  vomiting,  perhaps  some  fever,  and 
it  takes  a  day  or  two  to  regain  the  ordinary  state  of  health.  Headaches  due 
to  overwork  of  the  eyes  and  brain  are  especially  common  in  schoolboys  and 
girls  when  preparing  for  examinations  and  taking  too  little  exercise  and  re- 
creation. With  the  headache  there  is  often  sleeplessness  at  night,  anfemia, 
and  more  or  less  dyspepsia.  There  is  usually  no  difficulty  of  diagnosis  here, 
as  the  history  of  the  case  will  render  its  nature  plain. 

There  is  a  form  of  headache  which  is  by  no  means  uncommon,  which  is 
distinctly  neurotic,  and  which  does  not  appear  to  be  connected  in  any  way 
with  dyspepsia,  sluggish  liver,  overwork  at  school,  or  organic  disease.  The 
child  is  usually  a  girl  of  ten  or  twelve  years  of  age,  who  suffers  with  a  severe 
headache,  often  accompanied  by  sickness,  once  or  twice  a  week,  perhaps 
oftener,  which  comes  on  at  irregular  times,  and  is  sufficiently  severe  for  her 
to  take  to  bed  or  to  lie  on  the  sofa  for  most  of  the  day,  and  to  incapacitate  her 
for  all  work  or  play.  Such  headaches  are  made  worse  by  noises  and  exer- 
tion ;  at  times  there  is  violent  sickness  or  retching,  and  perhaps  giddiness  in 
the  erect  posture.  The  bowels  are  usually  constipated,  the  tongue  clean,  and 
in  the  intervals  between  the  attacks  the  child  is  in  good  health  and  able  to  go 


544  Diseases  of  the  Nervous  System 

to  school  and  take  moderate  exercise.  The  causes  of  such  headaches  are  verj^ 
difficult  to  discover  ;  a  tendency  to  such  is  often  hereditary,  and,  while  worse 
during  the  period  of  puberty,  the  tendency  may  remain  throughout  life. 
They  are  often  very  obstinate,  and  medicine  fails  to  relieve  as  long  as  the 
patient  remains  at  home,  leading  a  sedentary  town  life  ;  they  are  almost 
always  better  during  the  holidays  spent  away  at  the  seaside,  or  whilst  lead- 
nig  a  healthy  country  life,  but  recur  again  when  a  return  is  made  to  town 
life,  with  school  and  the  ordinary  home  routine. 

In  some  other  cases  the  headaches  are  more  distinctly  hysterical,  the 
pains  being  described  as  of  a  '  shooting  '  or  '  boring '  character,  and  coming' 
on  when  the  spirits  are  depressed  or  when  there  is  some  unpleasant  duty  or 
distasteful  study  to  be  undertaken.  On  the  other  hand,  all  headaches  are 
forgotten  if  the  patient  is  roused  by  some  excitement  or  the  prospect  of  some 
unusual  pleasure.  When  the  headache  is  present,  the  patient  demands  the 
sympathy  of  all  her  friends,  and  is  apt  to  lapse  into  a  chronic  invalid, 
expecting  to  receive  the  commiserations  and  attentions  of  the  whole  house- 
hold. She  objects  to  ex6rtion  of  any  kind  ;  the  least  noise  or  loud  talking 
brings  on  the  headache.  The  appetite  jaerhaps  becomes  poor,  she  becomes 
thinner,  and  the  whole  health  suffers,  or,  on  the  other  hand,  in  some  cases 
the  appetite  is  not  affected.  These  hysterical  headaches  are  commonest  at 
or  about  puberty,  when  menstruation  is  commencing,  but  they  may  be 
present  in  boys  and  in  girls  of  nine  or  ten  years  of  age. 

The  most  important  question  in  connection  with  diagnosis  is  with  regard 
to  the  presence  or  absence  of  organic  disease.  Are  tubercles  forming  in  the 
meninges  of  the  brain?  Is  there  a  cerebral  tumour,  or  are  the  headaches 
either  reflected  from  the  digestive  system  or  purely  nervous  in  character  ? 
The  diagnosis  between  cerebral  disease  and  functional  disease  is  usually  not 
difficult  if  the  history  given  by  the  friends  can  be  relied  upon,  or  if  there  is  an 
opportunity  of  watching  the  patient  for  a  few  weeks.  The  headache  accom- 
panying the  early  stages  of  tubercle  of  the  meninges  is  associated  with 
irritabilit}^,  wasting,  hectic  fever,  loss  of  appetite,  shivering,  and  cough  ;  and 
a  few  weeks  more  or  less  will  almost  certainly  see  developed  more  marked 
cerebral  symptoms,  such  as  squint,  vomiting,  and  involuntary  passage  of 
fseces.  The  headache  due  to  cerebral  tumour  is  mostly  constant,  though 
worse  at  times  than  at  others  ;  it  is  always  made  worse  by  movement ;  there 
are  erratic  and  apparently  causeless  vomiting  and  optic  neuritis. 

In  all  cases  of  persistent  headache  it  is  necessary  to  fi'equently  examine 
the  optic  discs  for  any  evidence  of  optic  neuritis.  We  have  known  several 
cases  in  which  headaches  were  after  awhile  accompanied  by  optic  neuritis 
followed  by  loss  of  sight  and  without  any  definite  cerebral  symptoms — the 
headaches  getting  well  in  thecourseof  many  months,  but  there  was  blindness 
from  optic  atrophy. 

Treatment. — The  treatment  of  headaches  is  naturally  directed  to  moving 
the  cause.  In  rapidly  growing  children  it  will  mainly  consist  in  the 
avoidance  of  over-exertion  or  fatigue,  and  in  ordering"  a  very  moderate 
amount  of  brain-work,  a  healthy  country  life,  and  a  careful  regulation  of  the 
diet.  The  digestive  organs  are  probably  being  given  more  work  than  they 
are  able  to  perform,  a  gastric  or  intestinal  catarrh  is  set  up,  and  the  disordered 
state  of  digestion  is  expressed  by  a  frontal  headache.     Vomiting  in  these 


Headaches  545 

cases  nearly  always  relieves  the  headache  ;  if  it  does  not  take  place,  perhaps 
there  may  be  feverishness,  nausea,  and  headache  for  a  day  or  two.  When 
these  headaches  are  coming  on,  the  simplest  and  best  remedy  is  an  emetic 
such  as  a  teaspoonful  or  two  of  ipecacuanha  wine,  to  be  followed  by  a  little 
judicious  starvation  or  the  lightest  possible  diet  for  a  few  days.  For  the 
avoidance  of  such  sick  headaches  meat  should  be  allowed  only  in  moderate 
quantities,  it  must  be  well  cut  up  and  masticated  slowly,  and  care  should 
l)c  taken  to  regulate  the  bowels  from  time  to  time  with  some  effer- 
vescing" citrate  of  potash,  Rubinat  or  Carlsbad  water,  before  breakfast.  In 
the  neurotic  forms  of  headache,  arising  independently  of  digestive  derange 
mcnts,  the  treatment  is  often  very  unsatisfactory.  When  the  attack  comes 
on,  and  is  evidently  severe,  bed  is  the  best  place,  with  a  wetted  handkerchief 
to  the  head  in  the  hope  of  getting  the  child  to  sleep  ;  coffee,  effervescing 
citrate  of  caffein  (i  to  2  grains  of  the  pure  salt),  monobromide  of  camphor 
( I  to  2  grains),  ext.  guaranas  lici.  ( 10  to  15  drops),  e.\t.  cannabis  indicte,  or  bro- 
mides are  often  beneficial.  Phenacetin  (2  to  5  grains)  has  been  used  with 
good  effect.  In  the  intervals  between  the  headaches  the  most  important 
treatment  relates  to  regulating  the  bowels  and  to  insisting  on  a  simple  but 
nutritious  diet.  In  some  cases  good  has  followed  the  entii'e  avoidance  of 
butcher's  meat  (Haig).  A  healthy  country  life  or  change  of  scene  is  often 
of  the  greatest  service  and  generally  effectively  cures,  for  a  while  at  least. 
In  hysterical  headaches  the  patient  should  be  encouraged  to  take  an  active 
interest  in  some  work  or  play. 

Uig-ht  terrors.- — These  attacks  are  allied  to  hysteria  and  are  common 
in  neurotic  girls  and  boys.  The  child,  who  has  perhaps  been  sleeping 
cjuietly  for  a  few  hours,  suddenly  sits  up  in  bed,  its  face  the  picture  of  horror 
and  fright,  while  it  shrieks  and  points  at  some  imaginary  object.  The 
appearance  of  the  friends  on  the  scene  does  not  pacify  it  ;  it  cannot  be 
aroused,  but  continues  to  be  affrighted  by  some  apparition.  After  awhile  it 
wakes  up  or  goes  off  quietly  to  sleep  again,  and  in  the  morning  knows 
nothing  of  the  night's  disturbance.  These  attacks  occur  several  times  during 
the  same  night  or  there  may  be  weeks  without  an  attack.  W^henever  night 
terrors  occur,  the  child's  diet  should  be  carefully  regulated,  especially  as 
regards  the  evening  meal.  Any  indigestion  should  be  treated  ;  a  dose  of 
bromide  at  night  may  be  given.     The  prognosis  is  good. 


N  N 


546  Diseases  of  the  Nervous  System 


CHAPTER   XXV 

DISEASES    OF   THE   NERVOUS    SYSTEM — ContillUed 

Speech  ilnomalies 

During  the  first  year  of  life  the  infant  is  unable  to  express  itself  by  means 
of  intelligent  speech,  nor  does  it  make  much  progress  in  the  understanding 
of  spoken  words.  A  cry  is  the  first  sound  uttered  by  the  infant;  it  is  a 
reflex  act,  the  stimulus  being  some  form  of  discomfort  or  pain.  Within  the 
first  two  months  (five  weeks,  according  to  Preyer)  variations  in  the  tone  and 
strength  of  the  cry  occur,  indicating  acute  pain  or  hunger  or  impatience. 
Later  still  the  cry  becomes  more  distinctive  and  expressive,  and  the  cry  of 
anger  or  disappointment  may  be  distinguished  from  the  cry  of  hunger. 
Smiling  may  be  observed  by  the  end  of  the  second  month  or  earlier  (twenty- 
third  day,  Preyer),  but  really  noisy  laughter  is  not  heard  till  several  months 
later.  Other  facial  expressions,  such  as  frowning,  rage,  sulkiness,  are 
noted  later  in  the  first  year.  From  the  earliest  months  the  infant  '  babbles  ' 
or  '  crows '  when  pleased  or  in  a  good  humour  ;  this  doubtless  is  a  sort  of 
instinctive  exercise  of  the  speech  organs.  It  seems  to  take  a  pleasure  in 
exercising  its  organs  of  speech,  in  much  the  same  way  that  it  derives  plea- 
sure from  lying  on  its  back  and  kicking  vigorously  in  an  aimless  sort  of  way. 
Both  consonant  and  vowel  sounds  are  produced  in  great  profusion,  but  in  an 
irregular  and  inco-ordinate  fashion.  Preyer  noticed  that  in  one  of  his  babies 
all  the  vowel  sounds  and  all  the  consonant  sounds  were  used  during  the  first 
seven  months  except  w,  s^  z,f,  and  sh  ;  all  the  latter  were  postponed  till  the 
second  year.  By  the  end  of  the  first  year  some  of  the  easier  consonant 
sounds,  such  as  mam-mam^  ba-ba,  dada,  nana,  are  repeated  in  a  meaningless 
sort  of  way,  but  before  long  they  are  applied  to  persons  and  things.  Some 
of  the  earliest  sounds  acquired  are  those  made  by  domestic  animals,  and  the 
child  quickly  uses  the  sound  to  name  the  animal.  The  understanding  of 
spoken  words  precedes  by  some  months  the  ability  to  express  ideas  in 
language.  In  answer  to  a  question  the  child  will  use  '  gesture  language '  in 
preference  to  articulate  speech.  It  will  point  to  the  object  named  or  express 
assent  or  dissent  by  nodding  or  shaking  its  head.  Many  feeble-minded 
children,  and  also  many  of  the  lower  animals,  as  the  dog,  will  understand 
spoken  words,  but  have  not  the  power  of  expressing  ideas  in  words.  During 
the  second  year  the  vocabulary  increases  fast,  the  child  quickly  imitating 
and  repeating  the  word  it  hears,  so  that  by  the  end  of  the  second  year  it  not 
only  uses  a  number  of  words  correctly,  but  can  string  a  few  nouns  and 
adjectives  together,  and  has  learned  the  meaning  of  short  phrases.     Thus 


Defects  in  Speech  547 

we  find  such  short  sentences  used  as  '  Kcftnie  come  in  mummy s  bed,'  or 
*  Kennie  no  liky  pudding.'  At  this  period,  and  for  the  next  year  or  two, 
words  are  indistinctly  or  improperly  pronounced,  with  a  tendency  to  clip 
them  short  or  to  drop  consonants.  Some  consonants  present  greater 
difficulty  to  the  young  child  than  others,  and  are  constantly  dropped  out  of 
words  ;  thus  s,  especially  when  it  precedes  another  consonant,  is  omitted,  as 
cool  for  school,  kwck  for  squeaky  no  for  snow.  Difficulties  often  arise  with 
the /// and  sh:  Ruth  becomes  Roof\  the  vibratory  consonant  ;- is  a  great 
stumbling  block,  and  the  distinct  pronunciation  of  it  is,  perhaps,  never 
acquired  :  grub  is  apt  to  h^covn^  gxvub,  and  roof,  woof. 

To  learn  to  speak  intelligently  there  must  be  : 

{a)  A  perfect  hearing"  apparatus  to  transmit  the  vibrations  of  sound  to  the 
auditory  centre. 

[b)  An  auditory  centre  which  translates  vibrations  of  sound  into  ideas. 

if)  '  Think  organs '  or  perceptive  centres. 

id)  Motor  speech  centre  (Broca's  convolution). 

{e)  Speech  apparatus  for  converting  motor  impulses  into  articulate 
speech. 

Some  children  are  more  backward  in  talking  than  others,  and  are  at  the 
same  time  behindhand  with  walking  and  cutting  their  teeth,  and  it  is  only 
after  the  end  of  the  second  year  is  passed  that  they  begin  to  make  progress. 
This  frequently  happens  with  rickety  children,  or  with  those  who  have  had 
some  serious  disease  to  contend  with.  Other  children  not  only  do  not  begin 
to  talk  when  the  usual  time  arrives,  but  as  months  and  years  go  on  make  no 
attempt,  or  their  articulation  is  indistinct  and  imperfect  for  their  age.  In 
another  but  smaller  class  the  child  learns  to  talk  fairly  well  or  imperfectly, 
then  an  illness  comes  on  and  it  loses  the  power  of  speech.  The  principal 
causes  of  imperfection  or  absence  of  speech  may  be  tabulated  thus  : 

1.  The  child  may  be  deaf  ;  it  is  mute  because  it  is  deaf  {a). 

2.  The  child  does  not  speak  distinctly,  there  may  be  some  defect  in  the 
organs  of  speech  (e). 

3.  The  child  is  feeble-minded,  the  '  think  '  organs  are  at  fault  {c). 

4.  There  is  motor  or  auditory  aphasia  {b  or  d). 

5.  The're  is  hesitancy  in  speech  due  to  '  stammering.' 

I.  Deaf-mutism. — Deaf-mutes  are  those  who  cannot  speak  because  they 
cannot  hear  :  the  deafness  may  be  due  to  congenital  defect,  or  they  may 
become  deaf  through  illness  before  they  have  learnt  to  talk  ;  as  a  rule,  if  the 
child  becomes  deaf  before  he  is  seven  years  of  age,  dumbness  results.  The 
cong-enital  variety  appears  mostly  to  be  the  result  of  hereditary  taint,  con- 
genital deafness  having  occurred  previously  in  the  same  family.  It  is 
doubtful  if  the  marriage  of  cousins  has  anything  to  do  with  it.  The  morbid 
anatomy  is  very  uncertain,  as  there  are  but  i&^N  post-mortem  records  of  such 
cases  ;  in  such  cases  there  is  reason  to  believe  that  congenital  deafness  is 
the  result  of  inflammation  of  the  internal  ear  during  intra-uterine  life  or  a 
failure  of  development  of  certain  nerve  centres.  How  early  is  it  possible  to 
detect  deafness  ?  The  diagnosis  is  necessarily  very  difficult  during  the  first 
few  months  of  life,  especially  when  we  remember  that  congenital  deafness  is 
rarely  complete,  the  ringing  of  bells,  Avhistling,  &c.,  being  heard  when  the 
ear  is  quite  incapable  of  detecting  articulate  sounds.     During  the  first  few 

N  N  2 


548  Diseases  of  the  Nervous  System 

weeks  after  birth  the  healthy  infant  gives  no  response  or  signs  of  recog- 
nising sounds,  but  loud  noises  will  wake  it  up.  It  is  only  during  the  third 
or  fourth  month  that  the  infant  appears  to  recognise  sounds  and  voices, 
but,  as  some  infants  are  more  backward  than  others  with  regard  to  percep- 
tions, it  is  only  after  six  months  of  age,  or  from  that  to  a  year,  that  a  definite 
knowledge  can  be  come  to  with  regard  to  deafness.  When  the  infant  is  a 
year  old,  and  has  never  uttered  an  articulate  sound,  while  it  shows  no  want 
of  intelligence  in  other  ways,  a.nd  its  muscular  power  and  growth  are  in 
accordance  with  the  normal  standard,  there  is  strong  reason  to  believe  that 
its  speech  defect  is  due  to  deafness.  The  diagnosis  between  a  failure  to 
speak  due  to  partial  deafness  or  failure  on  account  of  mental  feebleness  is 
often  extremely  difficult,  perhaps,  in  certain  cases,  for  a  time  impossible,  in 
the  absence  of  other  signs  of  mental  defect.  The  infant  may  be  tested  by 
means  of  a  loud  whistle,  bell,  or  clapping  hands,  care  being  taken  that  it 
cannot  see  the  performer,  while  its  face  is  watched  for  any  sign  of  recognition 
on  its  part.  A  confident  opinion  cannot  well  be  given  before  the  sixth  month. 
Parents  will  often  not  detect  deafness  till  the  child  is  much  older  than  this. 
On  the  other  hand,  parents  will  constantly  assert  that  a  feeble-minded  infant 
is  deaf  or  blind. 

In  the  following  case  the  diagnosis  was  very  difficult  at  first  : 

Annie  M.  C,  2  years  9  months.  First  child,  healthy  infant,  took  notice  in  the  usual 
way  at  2  or  3  months  of  age,  sat  up  at  6  months,  late  in  walking  at  15  or  16  months.  She 
'  jabbered  '  and  '  babbled '  like  any  other  infant  ;  at  9  or  10  months  said  '  dad  dad,'  '  ma?n 
mam,'  '  bab  bab  ;  '  at  12  months  said  '  dada,  dada,'  ^ ya,  ya,'  '  mam,  mam,'  and  later  called 
her  cousin  '  .Sam  '  '  am,  am.'  Some  difficulty  in  teaching  her  cleanl)^  habits.  The  child 
when  tested  is  absolutely  deaf,  cannot  hear  loud  whistles  or  voices. 

Presumably  the  articular  sounds  made  by  this  child  were  the  result  of 
'  instinct "  aided  by  watching'  the  lips  of  its  friends.  Many  deaf-mute  children 
seem  to  delight  to  make  shrieking  or  other  unpleasant  noises  with  their 
vocal  organs. 

iLcquired  Deaf-mutism. — When  a  child  under  seven  years  loses  its 
hearing  in  consequence  of  disease,  its  speech  becomes  indistinct  and  more  or 
less  uninteUigible,  and  it  loses  the  power  of  speech  altogether,  either  quickly 
or  gradually,  according  to  its  age  and  intelligence.  The  loss  of  speech  will 
necessarily  depend  to  some  extent  upon  the  amount  of  deafness.  According 
to  Hartmann,  it  is  possible,  if  the  child  is  intelligent,  and  great  care  is  taken 
to  correct  its  mistakes  in  talking  and  to  induce  it  to  talk,  that  speech  may  be 
retained. 

The  lesion  which  commonly  produces  deafness  is  an  inflammation  of  the 
labyrinth,  either  idiopathic  or  secondary  to  meningitis,  scarlet  fever,  tj'phoid, 
or  whooping  cough.  The  difficulty  of  distinguishing  between  acute  otitis  and 
meningitis  has  already  been  pointed  out  (p.  475),  and  consequently  the 
extent  to  which  deafness  is  produced  by  one  or  the  other  is  uncertain. 
Attacks  of  cerebro-spinal  meningitis  undoubtedly  frequently  produce  deaf- 
ness, as  does  also  scarlet  fever.  In  this  country  scarlet  fever  plays  a  more 
important  part  than  other  diseases  in  destroying  the  auditory  apparatus. 
Hartmann  believes  that  an  inflammation  of  the  labyrinth  and  consequent 
injury  to  the  terminal  apparatus  of  the  auditory  nerve,  and  not  suppuration  in 
the  middle  ear,  is  the  cause  of  deafness  :  though  the  latter  frequently  takes 


Defects  in  Speech  549 

place,  it  is  not  necessarily  present.     A  naso-phar>'ngeal  catarrh  seems  to  be 
an  occasional  cause  of  labyrinthine  disease. 

The  hearing  power  of  deaf-mutes  is  usually  tested  with  a  bell  and 
tuning-fork,  the  two  ears  being  tested  separately.  Statistics  collected  by 
Hartmann  show  that  in  865  cases  of  deaf-mutism  in  different  institutions  60 
per  cent,  were  totally  deaf,  about  one-fourth  (24-3  per  cent.)  heard  sounds 
such  as  the  ringing  of  a  bell,  while  15  per  cent,  heard  words  or  vowel  sounds 
when  pronounced  loudly  close  to  their  ears. 

2.  Physical  Defects  intbe  Mouth. — Parents  not  infrequently  bring  a 
child  to  consult  a  medical  man  with  regard  to  his  backwardness  or  indis- 
tinctness in  speech,  which  is  attributed  to  his  being  tongue-tied  or  to  some 
deformity  of  the  mouth  or  palate.  In  the  majority  of  such  cases  no  physical 
defect  can  be  detected,  the  defect  being  rather  in  the  nervous  mechanism 
of  speech.  It  is  quite  conceivable  that  a  more  than  usually  attached  frcenum 
may  be  present  and  interfere,  however  slightly,  with  the  movements  of  the 
tongue,  and  explosives  of  the  second  stop  position,  /,  d.  s.  are  badly  pronounced. ' 
A  highly  arched  or  deformed  palate  may  render  speech  imperfect,  the  child 
speaking  like  one  with  cleft  palate  ;  but  it  must  not  be  forgotten  that  weak- 
minded  children  often  have  high  palates,  while  their  defective  speech  is  due 
to  mental  feebleness.  Defective  speech  is  also  present  in  those  with  large 
tonsils  and  post-nasal  adenoids  ;  there  is  a  characteristic  'stuffiness'  about 
the  voice,  and  difficulties  with  the  nasal  resonants  w,  //,  ng,  inasmuch  as  in  the 
pronunciation  of  these  the  air  is  allowed  to  escape  through  the  anterior  nares. 
Paresis  of  the  soft  palate  may  be  present,  especially  after  diphtheria,  the 
voice  having  a  nasal  twang  and  difficulty  being  experienced  in  pronouncing- 
the  explosive  labials  p  and  b,  as  the  air  escapes  into  the  nasal  cavit\-,  the  soft 
palate  failing  to  act. 

3.  IVIental  Defect. — Perhaps  the  commonest  form  of  defecti\-e  speech  is 
connected  with  the  nervous  mechanism.  The  child  perhaps  appears  intelli- 
gent and  bright,  no  defect  can  be  discovered  in  the  mouth,  yet  his  pronunci- 
ation of  certain  sounds  is  defective,  as  if  he  had  not  perfect  control  over 
his  lips,  tongue,  and  vocal  cords.  He  may  have  especial  difficulty  wnth  the 
consonants  of'  the  third  stop  position,  as  k  and  g^  while  the  fricatives  tk 
and  ;-  are  often  great  stumbling-blocks.  Backward  children,  or  those  of 
intelligence  below  normal,  are  especially  apt  to  have  difficulties  in  pronuncia- 
tion, in  other  cases  the  intelligence  is  fully  up  to  the  average.  The  fault  lies 
presumably  in  Broca's  convolution.  A  boy  of  eight  years  whom  we 
examined  used  the  vowels  fairly  well,  but  the  only  consonants  he  used  were 
/,  ;;/,  /,  7?,  and  lii  ;  Sam  Brown  was  '  Pam  PowTi '  &c.  :  he  could  add  up 
simple  sums,  and  write  his  name,  but  he  was  generally  backward.  He  could 
not  pronounce  consonants  requiring  voice,  as  b^  d.  All  degrees  of  difficulrr 
of  speech  may  exist  :  it  may  be  so  m^arked  that  the  child  avoids  conversation 
as  much  as  possible,  and  expresses  his  assent  or  his  wants  by  signs.  This 
form  of  difficulty  of  speech  is  often  hereditary.  It  is  possible  that  in  some  of 
these  cases  the  hearing  is  at  fault  and  the  child  suffers  from  partial  word- 
deafness,  in  a  similar  way  to  a  child  suffering  from  colour-blindness,  or  a 
faulty   development   of  the   co-ordinating  motor   centre  of  speech.     Some 

1  See  'Some  Forms  of  Defective  Speech,'  Warrington  Haward,  Lancet,  vo!.  i.  p.  iii, 
1887. 


550  Diseases  of  the  Nervous  System 

children  talk  a  sort  of  gibberish  which  perhaps  their  brothers  or  sisters  under- 
stand, but  no  one  who  has  not  been  with  them  a  great  deal  can  make  out.' 

If,  however,  instead  of  imperfect  speech  the  child  of  five  or  six  years  of 
age  does  not  talk  at  all,  there  is  probably  some  mental  defect,  the  child  fail- 
ing to  understand  what  is  said,  or  although  it  may  understand  the  speaker, 
yet  there  is  a  failure  in  the  process  of  converting  thoughts  into  words. 

4.  Aphasia. — Children,  like  adults,  may  suffer  from  aphasia  due  to 
organic  disease,  or  from  a  functional  aphasia.  In  the  former  the  aphasia 
may  be  the  consequence  of  embolism  of  the  left  middle  cerebral  artery,  and 
be  associated  with  a  right  hemiplegia,  or  a  tubercular  tumour  may  compress 
the  left  third  frontal  convolution. 

Functional  aphasia  is  not  uncommon  and  occurs  usually  after  exhausting 
fevers  ;  as,  for  instance,  in  typhoid  after  the  febrile  stage  is  passed  many 
months  may  elapse  before  the  child  speaks.  It  may  occur  after  pneumonia  ; 
thus  a  child  of  two  and  a-half  years  suffered  from  inflammation  of  the  lungs 
in  October  ;  his  mother  said  his  talking  left  him  while  getting  better.  He 
did  not  speak  a  word  till  the  following  April,  when  he  said  '  Drink  ; '  the 
following  month  he  began  gradually  to  talk  again.     (See  also  case,  p.  520.) 

In  another  case,  kindly  sent  us  by  Dr.  Hodgson  of  Oldham,  a  boy  aged  two 
and  a-half  years  had  whooping  cough  and  was  convulsed  continuously  for  four 
hours;  he  talked  as  usual  for  a  day  or  two  after  this  attack,  then  ceased  to  talk, 
though  once  in  his  sleep  he  said  '  mamma.'  He  expressed  assent  when 
spoken  to  and  pushed  his  plate  if  asked  if  he  would  take  more  food  ;  he 
appeared  to  understand  what  was  said  to  him.  He  remained  in  this  state 
without  saying  a  word  for  two  months,  then  he  said  a  word  or  two  and  a  day 
or  two  after  completely  regained  his  speech  ;  and  shortly  became  as  great 
a  chatterbox  as  ever.  A  boy  under  our  care  with  spastic  paralysis  (see 
fig.  105)  could  not  speak  or  make  anyone  understand  except  by  signs,  and 
if  asked  his  name  he  pointed  to  his  name  written  on  his  bed  card  or  on  the  lid 
of  a  toy  box. 

The  power  of  speech  is  lost  suddenly  at  times  in  consequence  of  a  nervous 
break-down.  Dr.  Langdon  Down  records  the  cases  of  two  brothers,  who  had 
spoken  well  and  understood  two  languages,  completely  losing  the  power  of 
speech  at  the  period  of  the  second  dentition. 

5.  Staimnering-  occurs  occasionally  before  the  period  of  the  second  den- 
tition ;  it  is  often  hereditary,  and  is  always  worse  during  a  period  of  ill  health. 
Boys  are  far  more  commonly  affected  than  girls.  It  is  especially  apt  to 
supervene  in  boys  who  are  overworked  at  school,  and  who  inherit  neurotic 
tendencies. 

Treatment  of  Defective  Speech. — The  treatment  necessarily  depends  en  the 
cause  of  the  defective  speech.  Surgical  treatment  may  be  required  in  the 
first  place ,  enlarged  tonsils  must  be  excised  and  post-nasal  adenoids  removed, 
defects  in  the  hard  or  soft  palate  must  be  remedied  as  far  as  possible  by  sur- 
gical and  mechanical  means.  Special  instruction  in  articulation,  especially 
directed  to  the  difficult  sounds,  must  then  be  practised.  For  this  purpose 
the  teacher  faces  the  pupil,  showing  him  by  exaggerated  movements  of  his 
own  lips,  tongue,  or   larynx  the  positions  they  should  assume  to  form  the 

1  See  Dr.  W.  B.  Hadden,  'On  Certain  Defects  of  Speech  in  Children,' /ti //;-««:/  of 
Mental  Science,  January  1891. 


Defects  in   Speech  5  5  i 

desired  sounds,  and  practising  the  pupil  in  these  movements.  In  fact,  the 
oral  method  now  so  commonly  in  use  for  the  instruction  of  deaf-mutes 
must  be  practised  in  all  cases  of  defective  speech.  In  habitual  stammering 
the  child,  if  old  enough,  should  be  tested  (see  '  Physiological  Alphabet ' 
Appendix)  to  ascertain  the  chief  stumbling-blocks  among  the  consonants.  He 
should  be  taught  to  speak  slowly,  and  practise  the  consonants  over  which  he 
hesitates.     Breathing"  exercises  are  also  useful. 

The  education  of  deaf-mutes  has  received  much  attention  of  recent  years, 
more  especially  in  Germany,  and  schools  are  now  established  throughout  the 
country  where  the  education  of  deaf-mutes  is  carried  on  on  the  oral  system. 
By  this  system  the  senses  of  sight  and  touch  are  made  as  far  as  possible  to 
take  the  place  of  the  defective  sense  of  hearing". 

If  the  patient  has  become  deaf  after  he  has  learnt  to  speak,  everything 
must  be  done  to  assist  him  to  retain  the  faculty  of  speech  and  to  discourage  the 
use  of  sign-language.  The  child  must  be  encouraged  to  speak,  the  words 
that  are  wrongly  pronounced  being  corrected  as  far  as  possible  by  showing" 
the  child  the  exact  position  of  the  mouth,  lips,  tongue,  or  larynx,  and  by 
making  it  repeat  the  word  until  it  has  pronounced  it  correctly.  New  words 
are  taught  in  a  similar  manner,  and  by  showing  the  child  the  objects,  or 
pictures  of  the  objects,  taught. 

The  instruction  of  congenital  deaf-mutes  is  most  usefully  commenced  at 
six  years  of  age  ;  before  this  time  it  is  difficult  to  fix  the  child's  attention  for 
sufficiently  long  together  ;  indeed,  many  children  do  not  manage  to  learn 
much  till  they  are  seven  years  of  age.  It  need  not  be  said  that  the  training 
of  deaf-mutes  in  the  use  of  oral  language  is  a  tedious  and  difficult  process, 
recjuiring  a  special  training  and  much  patience  on  the  part  of  the  teacher. 
The  deaf-mute  has  not  only  to  learn  to  speak,  but  also  to  understand  what 
is  said  to  him  by  watching"  the  movements  of  the  speaker's  lips.  After  many 
years  of  training"  the  clever  deaf-mutes  are  able  to  leave  school  and  converse 
with  others  sufficiently  to  enable  them  to  learn  a  trade  and  earn  their  own 
living.^  Their  speech  is  necessarily  laboured,  each  syllable  is  emphasised 
and  the  tone  disagreeable  ;  we,  however,  kno"w  one  boy  of  sixteen  years  of 
age  who  has  been  completely  deaf  since  four  years  of  age  who  speaks  really 
■well  and  with  a  Lancashire  accent  !  He  was  taught  by  the  oral  method  at 
the  Old  Trafford  Schools,  Manchester- 
mental  Affections  in   Cbildhood 

All  degrees  of  intellectual  feebleness  are  met  with  during  infancy  and 
childhood,  ranging  from  complete  amentia,  the  result  of  an  ill-developed  or 
damaged  brain,  to  mere  backwardness  or  dulness  of  the  mental  powers. 
The  classification  of  such  is  roughly  made  when  "we  speak  of  idiots,  imbeciles, 
mentally  feeble  and  backward  children,  though  in  using  these  terms  it  must 
be  borne  in  mind  that  no  sharp  line  can  be  drawn  between  idiots  and 
imbeciles,  and  mentally  feeble  ;  moreover,  there  are  objections  to  both  terms, 
inasmuch  as  the  one  is  a  term  of  reproach  and  the  other  is  frequently  applied 
to  those  who  are  the  subjects  of  senile  dementia.    The  terms  '  feeble-minded  ' 

I  For  details  of  the  methods  of  oral  instruction,  see  Deaf-mutism,  by  Hartniann 
(Cassell's  translation). 


5  32  Diseases  of  the  Nervous  System 

and  'mentally-feeble'  are  usually  applied  to  children  Avho,  while  not  being  idiots 
or  imbeciles,  have  mental  powers  below  the  average,  and  are  in  consequence 
not  able  to  take  their  places  in  school  with  normal  children,  but  require 
special  education.  The  term  '  defective '  children  includes  those  of  feeble 
mental  powers  and  also  those  of  normal  mental  power,  who  by  reason  of 
physical  defects  cannot  be  taught  in  elementary  schools  by  ordinary  methods.' 
The  term  backward  children  rather  applies  to  children  of  slow  mental 
development,  or  who  are  mentally  slow  and  d.iU  for  their  years. 

No  classification  of  idiots  in  our  present  state  of  knowledge  of  pathology 
is  quite  satisfactory,  the  classes  being  certain  to  overlap.  We  will  speak  of 
the  following  groups  : 

1.  Congenital  idiocy.  4.  Backward  children. 

2.  Developmental  idiocy.  5.  Syphilitic  idiocy. 

3.  Accidental  or  acquired  idiocy.  6.  Cretinism. 

I.  The  cong^enital  group  includes  by  far  the  largest  class,  those  in 
whom  some  mal-development,  or  arrest  of  development  of  brain  or  some 
brain-damage  takes  place  during  intra-uterine  life,  and  who  in  consequence 
are  never  in  possession  of  average  intellectual  powers.  The  members  of 
this  group  usually  show  within  a  few  months  of  birth  that  they  are  not  like 
ordinary  children.  The  mother  notices  that  the  infant  when  a  month  or 
two  old  does  not  take  notice  as  it  should  do ;  it  pays  no  attention  to  a  bright 
light  or  sound,  it  does  not  recognise  its  friends  by  a  smile,  or  appear  to  hear 
its  nurse's  voice.  As  time  goes  on  it  makes  no  attempt  to  sit  up  or  hold 
toys  in  its  hands,  its  muscular  system  is  weak,  and  its  face  wears  a  vacant 
expression.  At  a  year  or  eighteen  months  old  it  has  made  no  progress  in 
walking  or  in  using  its  limbs,  or  perhaps  it  cannot  utter  any  articulate 
sound  ;  it  slavers  continually,  the  saliva  running  from  its  mouth  onto  its 
frock,  and  it  has  no  control  over  its  urine  and  faeces.  As  its  muscular 
power  gradually  increases,  it  learns  to  walk,  perhaps  to  say  a  few  words, 
and,  if  carefully  looked  after,  to  become  more  cleanly  in  its  habits.  At  three 
or  four  years  of  age  it  cannot  understand  anything  that  is  said  to  it,  it 
takes  no  notice  of  anything  in  its  daily  walk,  and  can  only  utter  one  or 
two  articulate  sounds.  Often  such  children  are  uncertain  in  their  temper 
and  mischievous. 

The  physical  characters  as  well  as  the  degree  of  intelligence  possessed 
by  congenital  idiots  are  very  various.  They  mostly  have  coarse,  harsh  skins, 
slow  circulations,  and  suffer  from  constipation.  They  are  exceedingly  apt 
to  suffer  from  various  tubercular  manifestations.  They  nearly  always  remain 
stunted  in  growth.  Congenital  idiocy  may  be  associated  with  a  peculiar 
formation  of  the  skull,  corresponding  roughly  to  the  configuration  of  the 
brain  inside  ;  while  some  crania  are  small,  it  must  not  be  supposed  that 
small  heads  are  constantly  present  in  congenital  idiots  ;  in  some  cases  the 
head  is  symmetrical  and  well-shaped,  and  of  average  size.  Congenital  idiots 
may  have  microcephalic  (Aztec  type)  or  small  heads,  macrocephalic  or 
large  heads,  dolichocephalic  or  long  heads,  brachycephalic  or  broad  heads. 
Sometimes  there  is  a  want  of  symmetry  on  the  two  sides  of  the  cranium,  or 

1  See  Report  of  the  Departmental  Committee  on  Defective  and  Epileptic  Children. 


Congenital  Idiocy  553 

there  is  a  deficient  development  of  the  frontal  or  occipital  region.  Various 
conditions  of  the  mouth  found  in  congenital  idiots  have  been  especially 
emphasised  by  some  authors  ;  these,  it  is  needless  to  say,  are  not  uni\er- 
sally  present.  The  palate  is  inordinately  high  and  arched,  or  more  decidedl)' 
V  -shaped,  and  often  unsymmetrical  ;  the  tongue  is  usually  large,  and  its 
mo\'ements  are  apt  to  be  badly  co-ordinated  and  awkward  ;  the  fungiform 
papilhe  are  hypertrophied  ;  the  mucous  membrane  of  the  pharynx  is  apt  to 
be  thickened  and  congested,  the  tonsils  hypertrophied,  and  post-nasal 
adenoids  may  be  present.  Slavering  due  to  paresis  of  the  muscles  of  the 
lips  and  tongue,  as  well  as  to  the  hypertrophy  of  the  glands  of  the  mouth, 
is  very  common.  The  late  Dr.  Langdon  Down  looked  upon  slavering  as  of 
some  diagnostic  importance,  being  nearly  always  connected  with  mental 
feebleness.  The  teeth  are  late  in  appearing  and  quickly  become  carious. 
The  semilunar  or  epicanthic  folds  are  often  present  at  the  inner  canthi  of 
the  eyelids,  the  eyes  may  be  set  too  close  together  or  too  widely  apart,  there 
may  be  strabismus,  nystagmus,  or  coloboma  iridis  present.  The  position 
and  shape  of  the  ears  are  worthy  of  attention  ;  they  may  be  large  and  stand 
out  from  the  head,  may  be  planted  abnormally  far  back,  be  abnormally 
adherent,  or  the  lobule  defective.  It  must  be  borne  in  mind  that  while  there 
has  been  an  arrest  of  the  development  of  the  brain,  other  malformations  may 
also  be  present,  such  for  instance  as  cleft  palate,  or  some  malformation  of 
the  heart,  as  an  open  foramen  ovale,  or  imperfect  ventricular  septum.  The 
fingers  may  be  webbed  or  stunted.  We  have  already  noted  that  nearly  all 
congenital  idiots  have  poor  circulations,  suffering  from  cold  feet  and  hands  and 
chilblains,  and  it  may  be  added  that  their  sensation  is  defective  and  wounds 
of  the  extremities  are  long  in  healing.  The  fingers  may  be  'webbed'  or 
stunted.  '  The  dyscrasia  which  accompanies  or  causes  genitous  idiocy,'  says 
W.  W.  Ireland,  '  affects  both  the  constitutional  vigour  and  the  symmetrical 
growth  of  the  frame,  though  not  equally  in  eveiy  part.  Nature  works  like  a 
bad  sculptor,  who  fails  to  give  the  proper  form  sometimes  to  one  member 
of  the  body  and  sometimes  to  another.  There  are  errors,  now  here  and  now 
there  ;  and  some  parts  are  more  happily  shaped  than  others.  Occasionally, 
however,  genitous  idiots  are  strong  and  good-looking,  with  well-formed 
heads,  good  teeth,  and  no  deformities  whatever.' 

With  regard  to  the  sensory  and  mental  deficiencies  of  congenital  idiots, 
space  will  not  allow  us  to  enter  into  detail,  and  the  reader  is  referred  to 
special  treatises  on  the  subject.'  Among  idiots  there  are  those  who  live  out 
their  lives  giving  but  scant  evidence  of  the  possession  of  any  intellectual 
powers  ;  they  are  absolutely  helpless,  and  would  starve  if  food  was  not  actually 
put  into  their  mouths.  They  can  hardly  be  said  to  be  conscious,  or  their 
consciousness  is  of  the  indistinct  kind  ;  they  heed  neither  sights  nor  sound, 
they  make  no  voluntary  effort.  On  the  other  hand,  in  some  imbeciles  there  is. 
evident  talent,  if  not  genius,  in  some  directions,  while  in  other  ways  at  ten  or 
twelve  years  of  age  they  are  little  else  than  infants.  Thus  one  boy  of  seven- 
teen years  of  age  we  know,  can  distinguish  Schubert  and  Beethoven's  works 
at  once  when  he  hears  the  music,  and  can  understand  both  English  and 
German   in  conversation,  but  he  cannot  add   two  and  three  together  or 

1  ^ca  Mental  Affections  of  Chi Idfcu.  W.  W.  Ireland,  1898. 


554  Diseases  of  the  Nervous  System 

recognise  a  single  letter.  He  cannot  dress  or  even  properly  feed  himself. 
While  some  imbecile  children  are  exceedingly  good-natured  and  can  be 
easily  managed,  others  are  very  much  the  reverse.  As  infants  they  are  con- 
stantly crying  without  apparent  reason,  and  wear  out  the  patience  of  nurses 
and  mothers.  When  a  little  older  and  able  to  crawl  or  walk— though 
always  late  in  doing  so— they  are  everlastingly  in  mischief.  They  are  not 
still  for  a  moment,  and  it  is  at  least  one  person's  business  to  manage  them. 
When  they  cannot  have  what  they  want  there  is  an  unearthly  shriek  quite 
unlike  a  normal  child ;  they  will  eat  dirt  or  the  wool  off  the  blankets,  and  are 
apt  to  masturbate.  They  will  bite  or  pinch  or  kick  or  scream  for  hours  if 
not  allowed  their  own  way.  It  is  exceedingly  difficult  to  get  their  attention 
for  many  moments  together. 

There  are  one  or  two  well-marked  varieties  of  congenital  or  '  genitous ' 
idiocy,  and  among  these  the  mong-olian  type  first  pointed  out  by  Langdon 
Down  is  worthy  of  note.  On  account  of  their  resemlalance  to  the  Kalmuc  or 
Tartar  tribes  of  Asia,  the  name  Mongol  has  been  retained.  Their  appearance 
is,  according  to  Dr.  J.  Thomson,  characteristic  at  birth,  certainly  it  is  in  many 
cases  at  a  few  months  old,  as  we  have  had  several  opportunities  of  observing. 
The  most  striking  feature  is  the  obliquity  of  their  eyes,  the  axis  of  the 
palpebral  fissures  sloping  inwards,  the  eyelids  are  habitually  half-closed, 
from  the  drooping  of  the  upper  lid,  giving  them  an  '  almond'  shape.  This 
oblicjuity  of  the  eyes  is  often  not  well  seen  in  photographs  if  the  patient  is 
watching  the  performance.  The  tongue  is  large  and  protrudes  partially 
from  the  mouth,  the  papillae  are  prominent,  and  the  mucous  membrane 
fissured.  The  head  is  mostly  rounded,  often  small ;  their  hands  are  broad 
and  squat.  Mongolian  babies  are  late  in  holding  up  their  heads,  sitting  up, 
or  learning  to  walk.  They  are  late  in  learning  to  talk  and  backward  in 
bodily  development.  They  are  apt  to  suffer  from  congenital  heart  disease, 
and  easily  succumb  if  attacked  with  bronchitis,  pneumonia,  or  scarlet  fever. 
Many  die  of  tuberculosis,  and  only  a  small  proportion  reach  adult  life. 

The  child  (fig.  ii6)  was  a  Mongolian  idiot  who  died  of  pneumonia  at  two 
and  a-half  years  of  age.  He  could  not  walk  or  talk  and  understood  very 
little  of  what  was  said  to  him.  His  head  measured  i8|  in.  in  circumference. 
He  did  not  care  much  for  toys,  unless  they  made  a  noise.  He  never  smiled. 
His  brain  was  of  nearly  average  weight,  37  oz.,  the  convolutions  were  fairly 
well  marked,  and  to  the  naked  eye  the  appearance  was  normal. 

Another  well-marked  group  of  congenital  imbeciles  is  formed  by  the 
cretins,  but  these  will  be  described  later  (p.  559). 

laicrocepbalic  idiots  mostly  belong  to  the  congenital  division,  the  brain 
having  suffered  damage  during  intra-uterine  life,  or  there  has  been  an  arrest 
of  development.  Of  the  former  the  case  figured  (96  and  97)  on  p.  482  is  a  good 
example.  Microcephaly  from  arrest  of  development  of  the  brain  in  an 
extreme  degree  is  not  common,  though  several  remarkable  cases  are  on 
record  (Ireland,  Shuttleworth,  Beach)  in  which  the  brain  has  been  examined 
after  death.  On  account  of  the  early  closure  of  the  fontanelle,  sometimes 
before  the  fifth  month,  it  has  been  hastily  assumed  that  the  premature  closure 
of  the  skull  has  prevented  the  development  of  the  brain  and  craniotomy  has 
been  performed  with  the  idea  of  allowing  expansion.  Such  operations  have 
been  failures,   inasmuch   as  they  are  the  result  of  a  mistaken  pathology 


Hydrocephalic  Idiots 


555 


Microcephalic  idiots  are  mostly  dwarfs,  and  in  extreme  cases  are  of  very  limited 
intelligence  ;  they  are  quiet  and  docile,  but  capable  of  very  little  education. 

Hydrocephalic  idiots  may  belong  to  the  congenital  division,  the  child 
being  born  hydrocephalic  or  it  may  become  so  after  birth.     A  large  propor- 
tion of  hydrocephalics  die  during  infancy  or  childhood;  those  that  survive  • 
show  more  or  less  want  of  intelligence.     In  the  worse  cases  there  is  spastic 
contraction  of  the  limbs  and  complete  dementia. 

Eclampsic  Idiocy. — Some  infants  suffer  from  eclampsia  almost  from 
birth,  the  attacks  occurring  many  times  daily  ;  nearly  all  such  show  want  of 
intelligence  for  their  years.  In  post-mortem  examination  of  the  brain  of 
such  cases  we  have  found  nothing  as  far  as  naked  e)'e  appearances  go  to 
account  for  the  fits.     It  is  certain,  however,  that  small  haemorrhages  may 


Fig  .116. — Joseph  B.,  aged  i\  years,  Mongol  Imbecile. 


take  place  as  the  result  of  the  fits  and  other  changes  secondary  to  the  con- 
stant mechanical  congestion  of  the  veins  of  the  membranes  of  the  brain 
taking  place.  The  eclampsia  is  in  reality  of  the  epileptic  type,  an  unstable 
condition  of  the  nerve  centres  of  which  we  see  similar  examples  in  asthma 
and  cyclic  vomiting.  The  constant  occurrence  of  fits  certainly  leads  to 
exhaustion  of  nervous  force  and  dulling  of  the  intelligence.  Eclampsia  is 
much  more  common  in  all  forms  of  idiocy,  excepting  Mongols  and  cretins, 
than  in  normal  children. 

Epileptic  Idiocy. — It  is  not  easy  to  draw  the  line  between  eclampsic  and 
epileptic  idiocy — in  other  words,  between  infants  who  suffer  from  fits  and  who 
are  more  or  less  imbeciles  or  mentally  feeble,  and  older  children  who  suffer 
from  fits  of  the  epileptic  type.  In  a  few  cases  we  find  children  of  the 
highest  mental  powers  who  suffer  from  occasional  fits,  but  on  the  other 


556  Diseases  of  the  Nervous  System 

hand  confirmed  epileptics  usually  show  some  mental  dulness  or  mental 
obliquity.  Some  of  the  worst  forms  of  idiocy  are  associated  with  epilepsy, 
as  can  be  seen  by  a  visit  to  a  large  asylum  for  idiots  or  to  a  lunatic  asylum. 
Some  of  the  hemiplegic  idiots  suffer  from  epilepsy. 

2.  Developmental.' — In  this  group  are  included  those  Avho  show  no 
marked  signs  of  being  wanting  in  intelligence  during  infancy,  but  who  during 
childhood  or  youth  may  show  signs,  often  suddenly,  of  a  mental  breakdown 
and  arrest  of  the  development  of  the  mental  powers.  This  change  may  come 
at  any  time  during  childhood,  but  more  especially  on  the  approach  of  puberty. 
This  sudden  change  often  comes  as  a  great  surprise  to  the  friends  ;  the 
child's  head  is  well  formed,  he  looks  intelligent,  quite  unlike  the  appearance 
of  an  idiot,  and  they  are  at  a  loss  to  account  for  the  change,  or  attribute  it 
to  some  trifling  disorder.  Sometimes  the  first  intimation  of  the  crisis  is  that 
the  child  ceases  to  talk  :  such  was  the  case  in  a  little  boy  seen  by  us,  who 
was  perfectly  intelligent  and  bright  up  to  4|-  years,  when  he  suddenly  ceased 
to  speak  and  gave  over  playing  with  toys,  his  principal  employment  being 
to  throw  his  toys  on  the  floor  and  proceed  to  kick  them  about  the  room  ;  he 
hardly  seemed  to  know  his  mother,  though  at  other  times  he  appeared  to 
understand.     He  eventually  recovered. 

In  other  cases  the  change  comes  at  the  second  dentition  or  at  puberty  : 
such  children  are  apt  to  be  moi'bidly  conscientious,  believe  they  have  told 
lies  or  stolen,  or,  on  the  other  hand,  they  become  wayward,  mischievous, 
unkind  to  their  brothers  and  sisters,  and  disobedient.     (See  Hysteria.) 

Epileptic  fits  are  apt  to  appear  at  this  period  Dr.  Langdon  Down  has 
noticed  that  these  cases  often  have  a  scaphocephahc  head,  which  is  '  prow- 
shaped'  anteriorly,  the  prow  corresponding  with  the  inter-frontal  suture, 
which  forms  a  prominent  ridge.  Such  cases,  according  to  this  author,  are 
apt  to  break  down  by  over-pressure  at  school  or  from  over-excitement  during' 
childhood. 

3.  Acciaental  or  Acquired. — To  this  class  belong  those  who  do  not 
inherit  any  insane  tendency,  and  who  would  become  health}',  intelligent 
children  but  for  some  accident  which  damages  the  brain  at  birth,  or  some 
lesion  at  a  later  period.  Reference  has  already  been  made  to  cases  of  post- 
partum paralysis  (see  p.  502)  due  to  meningeal  haemorrhage  occurring  during 
birth  ;  such  are  often  not  only  paralysed,  but  mentally  feeble.  There  is  strong 
reason  to  believe,  as  already  stated,  that  damage  done  to  the  convolutions 
on  the  surface  of  the  brain  by  a  meningeal  haemorrhage  when  an  infant  is 
in  a  condition  of  asphyxia  is  the  cause  of  the  feebleness  of  intellect,  and 
possibly  such  cases  may  escape  paralysis,  the  motor  centres  escaping  damage. 
In  another  class  of  case  the  infant  is  quite  well,  and  its  development  is  satis- 
factory, till  it  has  some  acute  illness  with  cerebral  symptoms,  mostly  during 
its  second  year.  This  may  be  followed  by  hemiplegia,  or  there  may  be  no 
paralysis,  but  the  mental  development  is  interfered  with.  Such  children 
often  suffer  from  convulsions  and  finally  become  epileptics. 

Most  of  the  cases  of  hemipleg-ic  and  parapleg-ic  idiocy  come  under  this 
head,  and  also  many  of  those  who  suffer  from  general  or  partial  athetosis. 
In  these  cases  the  limbs  are  perfectly  quiet  and  relaxed  when  the  patient  is 
asleep  or  undisturbed,  but  when  excited,  or  when  any  voluntary  movements 
are  attempted,  there  are  a  series  of  erratic  and  violent  movements  which  are 


Accidental  Idiocy  557 

not,  or  are  only  prntially,  controlled  by  the  will.  The  legs  are  crossed  and 
rigid,  with  the  great  toe  dorso-flexed,  the  hands  make  a  series  of  clumsy  and 
irregular  movements,  with  the  wrists  flexed  and  the  fingers  alternately  flexed 
and  extended.  All  degrees  of  mental  imbecility  are  associated  with  athetosis. 
Athetosis  also  occurs  in  late  hemiplegia. 

Congeriifal  /liiocy  'U'ifh  Athetosis. — William  H.  D.,  aged  4  years.  Birth  easy,  has  never 
been  right,  cannot  sit  up,  or  walk  or  talk.  Is  a  well-nourished  boy,  head  small  (i8-in. 
eircumference),  small  development  in  front.  He  smiles  when  he  sees  a  watch,  understands 
when  asked  if  he  will  have  a  drink.  Lies  quiet  when  undisturbed  ;  when  moved,  or  when 
he  tries  to  sit  up  or  reach  out  his  hand  for  anything,  the  movements  begin.  If  he  tries  to 
pick  up  a  coin,  his  hands  and  arms,  legs,  face  are  thrown  into  erratic  and  vigorous  move- 
ment. He  perhaps  seizes  the  coin  after  several  attempts,  then  it  is  flung  out  of  his  hand. 
Tries  to  speak  and  makes  a  puffing  noise  with  his  lips.  He  manages  to  get  out  '  ma,'  '  ta,' 
'  ye,'  '  na,'  &c. 

Traicviatic  Idiocy  'with  Athetosis. — Miles  G.,  loyears.  Birth  difficult  and  instrumental. 
He  has  always  held  his  limbs  more  or  less  stiff,  this  was  more  noticeable  at  10  months  of 
age  than  before.  He  cannot  speak,  but  makes  a  grunt  for  '  yes '  and  another  different 
grunt  which  means  '  no.'  He  understands  something  of  what  is  said  to  him.  The  head 
is  rather  small,  being  somewhat  flattened  in  the  parietal  regions  and  '  also  narrow  in 
front.  He  lies  quite  quiet  and  helpless  in  bed  when  left  to  himself;  when  disturbed,  or 
when  anyone  goes  near  him,  the  movements  begin.  He  arches  his  back,  moves  his  head, 
makes  grimaces,  arms  and  hands  are  extended  and  flexed  alternately,  the  wrists  are  flexed, 
there  is  spasmodic  opening  and  closing  of  the  fingers.  The  legs  are  crossed,  the  knee 
extended,  the  foot  points,  the  great  toe  is  dorso-flexed.  When  left  to  himself  the  move- 
ments quiet  down.     He  cannot  feed  himself,  or,  indeed,  in  anyway  attend  to  his  wants. 

4.  Dull  and  Backward  Children. — The  name  sufficiently  indicates  this 
class  of  case.  It  is  often  difficult  to  say  whether  a  child  is  only  behindhand 
in  development  or  his  mental  powers  are  deficient.  In  most  cases  time  will 
decide  this.  Backwardness  is  at  times  associated  with  epileptiform  fits,  or 
other  nervous  troubles.  Children  of  this  class  are  a  constant  source  of 
anxiety  to  their  parents  ;  they  go  to  school  and  always  gravitate  to  the 
bottom  of  their  class,  being  perhaps  left  behind  by  their  younger  brothers 
or  children  many  years  younger  than  themselves  ;  out  of  school  they  are 
bullied  or  teased  by  their  playmates.  It  is  often  difficult  to  know  what  to 
do  with  them  ;  certainly  neither  a  large  school  nor  home  life  is  suitable. 
They  are  best  educated  in  a  small  school  where  backward  boys  are  received 
and  special  attention  paid  to  them. 

Many  of  these  dullards  will  be  found  attending  ordinary  board  schools, 
who  after  perhaps  four  or  five  years'  attendance  cannot  add  up  two  or  three 
simple  figures,  or  have  to  do  so  with  the  aid  of  their  fingers  or  by  dots  made 
on  paper.  Sometimes  there  is  what  appears  to  be  '  word  blindness.'  Thus 
a  boy  of  eleven  years,  after  having  been  five  years  at  a  Board  school,  could 
not  read  the  simplest  words  correctly  or  write  from  dictation,  but  could  add 
up  figures  quickly  and  correctly.  He  was  clever  with  tools  and  of  normal 
intelligence  in  every  way  except  in  learning  reading  and  writing  from  dicta- 
tion. He  could  write  a  good  hand  from  a  copy.  Backward  children  very 
frequently  articulate  badly,  drop  letters  out  of  words,  and  use  the  easy  letters, 
as  p,  b,  d,  (S:c.,  in  place  of  the  difficult  ones. 

5.  Idiocy  due  to  Cong^enital  Syphilis. — The  statistics  of  asylums 
for  idiots  and  imbeciles  do  not  support  the  view  that  mental  feebleness 
in  children  is  due  to  any  large  extent  to  the  results  of  inherited  syphilis. 


558  Diseases  of  the  Nervous  System 

Dr.  G.  E.  Shuttleworth  ^  records  that  out  of  i,ooo  inmates  at  the  Royal  Albert 
Asylum  for  Idiots  at  Lancaster,  in  only  ten  cases  was  there  any  reason  for 
suspecting  syphilis,  and  in  four  only  was  the  evidence  satisfactory.  We 
have  already  referred  (pp.  454  and  482)  to  certain  lesions,  such  as  meningo- 
encephalitis and  endarteritis,  which  give  rise  to  brain  softening  and  complete 
dementia  ;  but  such  cases  are  rare,  and  are  usually  fatal  at  a  comparatively 
early  period  of  life.  The  commoner  form  of  syphilitic  idiocy  does  not 
manifest  itself  till  the  child  is  some  six  or  seven  years  old,  or  even  later,  and 
takes  the  form  of  a  sort  of  dementia  or  nervous  breakdown.  The  child 
has  perhaps  learnt  to  read  and  shown  a  fair  amount  of  intelligence  ;  it  then 
gradually  becomes  more  and  more  stupid  and  dull,  and  finally  becomes 
completely  demented.  There  is  usually  a  general  paresis,  so  that  the  child 
cannot  stand  or  sit  up  and  has  to  keep  his  bed.  This  paresis  comes  on 
gradually  in  some  cases,  being  associated  with  choreiform  movements  or 
epileptic  seizures.  The  dementia  in  time  becomes  well  marked,  so  that  the 
child  does  not  recognise  his  friends  or  understand  anything  said  to  him. 
The  course  of  the  disease  is  chronic,  lasting  for  years,  so  that  such  patients 
often  finally  drift  into  the  workhouse  infirmaries.  They  rarely  are  seen  in 
Idiot  Asylums,  as  the  paresis  mostly  comes  on  before  the  dementia.  In  some 
few  cases  we  have  seen  children  suffering  from  syphilis,  who  have  become 
first  dull  and  backward  and  later  mischievous  and  half  insane.  In  all  such 
cases  it  is  important  to  inquire  for  a  history  of  syphilis,  and  to  cai'efully 
examine  the  patient  for  evidence  of  this.  Keratitis,  scarring  about  the  mouth, 
pegged  teeth,  disseminated  choroiditis,  &c.,  should  be  looked  for. 

The  changes  found  in  the  brain  in  these  cases  consist  in  a  chronic  end- 
arteritis and  meningitis  ;  there  is  also  thickening  of  the  skull. 

Morbid  Ajiato my. — Space  will  not  allow  of  any  description  of  the  malfor- 
mations or  lesions  found  in  the  brains  of  idiots  or  imbeciles.  The  varieties 
of  malformation  found  are  very  numerous  ;  the  brain  may  be  abnormally 
small,  the  frontal  or  posterior  lobes  may  be  ill-developed,  the  two  halves 
may  not  correspond,  or  the  corpus  callosum  or  commissures  may  be  absent. 
In  another  class  of  case  there  may  be  chronic  meningitis,  pachymeningitis, 
or  atrophy  of  the  cortical  centres. 

Treatment. — The  physical  and  intellectual  training  of  children  of  deficient 
mental  power  is  best  undertaken  in  some  institution  specially  equipped  for 
the  purpose.  Home  is  certainly  not  the  best  place  for  their  education.  In 
the  large  majority  of  instances  they  are  either  over-indulged  or  neglected  by 
their  parents,  brothers,  and  sisters.  The  association  of  the  cleverer  brothers 
and  sisters  often  produces  a  feeling  of  discouragement  in  the  feeble-minded, 
and  of  hopelessness  at  the  wide  gap  which  separates  them  from  others.  The 
discipline  of  a  well-managed  school  or  institution  is  of  the  greatest  advantage 
in  teaching  them  self-control  and  self-respect,  and  the  companionship  of 
those  who  are  more  or  less  on  an  equality  as  far  as  intelligence  is  concerned 
is  calculated  to  bring  out  their  mental  powers  far  more  than  is  the  association 
with  those  that  are  greatly  their  superiors.  If  a  school  education  is  necessary 
for  the  children  of  parents  who  are  in  comfortable  circumstances,  how  much 

1  'The  Influence  of  Hereditary  Syphilis  in  the  Production  of  Idiocy  or  Dementia,'  by 
J.  S.  Bury,  M.D. — Brain,  Part  XXI.  '  Idiocy  and  Imbecihty  due  to  Inherited  Syphilis,' 
by  G.  E.  .Shuttleworth,  B.A.,  M.D. — America?!  Journal  of  Insanity,  January  1888. 


Treatinc7it  of  Mental  Defects  559 

more  is  the  shelter  of  an  institution  necessary  for  the  feeble-minded  among 
the  lower  classes  I  The  Board  school  refuses  to  be  troubled  with  them  ;  they 
are  teased  and  worried  by  their  companions  in  the  streets,  while  they  are 
alternately  over-indulged  or  scolded  and  neglected  by  their  parents  ;  their 
life  is  miserable,  and  they  grow  up  useless  members  of  society  and  an 
encumbrance  to  their  friends.  Unfortunately  the  several  excellent  public 
institutions  for  the  training  and  education  of  feeble-minded  children  in  this 
country  are  too  few  in  number  for  the  work  they  have  to  do.  Moreover,  they 
labour  under  an  unfortunate  name,  viz.  'Asylums  for  Idiots  and  Imbeciles,' 
when  as  a  matter  of  fact  they  are  not  asylums  for  providing  a  home  for 
useless  members  of  society,  but  schools  where  weak-minded  children  are 
trained  to  take  their  part — though  a  very  minor  part — in  the  battle  of  life. 
These  circumstances  undoubtedly  operate  in  the  minds  of  parents,  who 
migdit  otherwise  be  not  averse  from  sending  their  children  to  training  schools, 
but  who  shrink  from  branding'  them  as  idiots  or  imbeciles. 

It  is  needless  to  say  that  children  who  are  idiots  or  weak-minded  need  a 
plentiful  supply  of  good  food  ;  and  that  especial  care  must  be  taken  to  keep 
their  apartments  warm  as  well  as  ventilated,  as  they  are  exceedingly  prone  to 
suffer  from  pneumonia  and  tuberculosis. 

During  the  last  few  years  special  classes  for  dull  and  defective  children 
have  been  provided  by  the  School  Boards  of  several  of  our  large  cities,  as,  for 
instance,  in  London  and  Bradford.  It  was  found  that  such  children  made 
no  progress  in  the  ordinary  classes  or  in  the  infant  school,  and  required 
special  training.  In  these  classes  musical  drill,  object  lessons  and  drawing, 
naturally  take  a  prominent  place.  Similar  classes  are  being  established  in 
other  cities  at  the  present  time. 

Craniectomy. — Recently  an  operation  under  this  name  has  been  intro- 
duced, based  on  the  supposition  that  in  certain  cases  of  mental  deficiency 
the  defect  is  due  to  premature  closure  of  the  cranial  sutures  and  consequent 
arrest  of  growth  of  the  brain.  The  operation  consists  in  the  removal  of  a 
strip  of  bone  along  one  or  both  sides  of  the  middle  line  of  the  skull,  or  in 
some  cases  over  the  motor  area,  thus  allowing  the  brain  room  to  grow.  The 
operationis  a  somewhat  serious  one,  and  we  do  not  think  it  has  been  followed 
by  any  permanent  improvement.  We  have  tried  it  in  two  cases  of  hopeless 
deficiency,  the  result  of  infantile  meningeal  heemorrhage,  but  in  such  condi- 
tions, as  might  have  been  expected,  no  marked  improvement  followed.  It  is 
clear  that  a  good  result  can  only  be  looked  for  when  the  brain  is  small  and 
undeveloped,  but  not  actually  anywhere  destroyed.  Both  our  cases  recovered, 
but  in  one  there  was  for  a  time  marked  hyperpyrexia,  apparently  a  direct 
result  of  the  operation  from  disturbance  of  the  brain,  and  not  due  to  septic 
causes  ;  one  of  [Mr.  Horsley's  cases  died  of  a  similar  condition.  The  brain 
from  one  of  our  cases,  which  died  some  months  after  the  operation  from 
causes  unconnected  with  it,  is  figured  at  page  509. 

6.  Cretinoid  Idiocy.  Sporadic  Cretinism.  Congrenital  IVIyxoedeiua. — 
Cretinism  is  endemic  in  mountainous  districts  of  Europe,  especially  in  the 
Swiss  Alps  ;  it  is  comparatively  rare  in  this  country,  though  examples  may 
be  met  with  in  the  hilly  parts  of  Derbyshire,  Yorkshire,  and  Somersetshire. 
Examples  of  this  form  of  cretinism  may  be  met  with  in  asylums.  Dr. 
Shuttleworth  records  a  remarkable  case,  who  died  at  the  age  of  twenty  years 


56o 


Diseases  of  the  Nervous  System 


in  the  Royal  Albert  Asylum  at  Lancaster.  In  such  cases  there  is  usually, 
but  not  universally,  an  enlarged  thyroid  gland,  and  goitre  usually  prevails 
in  the  same  localities. 

The  form  of  cretinism  of  most  interest  is  the  form  which  was  described 
by  Hilton  Fagge  under  the  name  of  'sporadic  cretinism.'     It  is,  however, 
by  no  means  unlikely  that  these  cases  are  in  reality  more  related  to  myx- 
oedema  than  to  the  form  of  cretinism  so  well  known  in  the  mountainous 
districts  of  Europe.     They  differ  from  the  latter  in  that  the  thyroid  is  absent, 
and  the  skin  and  subcutaneous  tissues  are  thick  and  myxoedematous.     Ex- 
amples   of    this    form    have 
been  met  with  in  all  parts  of 
this    country,    Europe,    and 
America.  Endemic  cretinism 
is    apparently    unknown    in 
America,  while  sporadic  cases 
are  not  uncommon  in  New 
York   and    other    American 
cities  (Roplik). 

In  many  of  the  cases 
which  have  come  under  ob- 
servation there  has  been  a 
history  of  the  child  being 
born  of  healthy  parents, 
and  of  being  well  till  some 
illness  occurred,  such  as 
measles  or  typhoid  fever, 
after  which  the  child  ceased 
to  grow  and  gradually  de- 
veloped the  pecuUar  physio- 
gnomy of  cretinism.  In  one 
of  our  own  cases  the  boy 
was  said  to  have  been  well 
till  an  attack  of  enteric  fever 
at  seven  years  of  age  ;  in  a 
case  recorded  by  Fletcher 
Beach  the  disease  dated  from 
whooping  cough  at  twenty 
months.  But  it  must  not  be 
forgotten  that  the  ignorant 
classes  are  very  unobservant,  and  are  apt  to  attribute  idiocy  or  backwardness 
to  some  acute  disease,  rather  than  acknowledge  it  has  existed  from  birth. 
In  other  cases  the  history  points  to  the  child  having  been  affected  from 
birth.  There  is  reason  also  to  believe  that  cretinoid  changes  are  in  opera- 
tion during  pregnancy,  and  that  some  of  the  cases  in  which  softening  of  the 
bones  is  supposed  to  be  due  to  infantile  osteo-malacia  are  in  reality  foetal 
cretinism.  There  can  be  little  doubt  that  cretinism  is  overlooked  during  the 
first  months  or  even  years  of  life,  inasmuch  as  the  physiognomy  and  sym- 
ptoms are  not  as  well  marked  as  they  are  later  on.  Such  infants  may  never 
be  brought  to  a  doctor  for  advice,  or  the  parents  may  seek  advice  only  on 


-A  Cretin  four  years  of  age 
not  stand  without  help. 


She  could 


Cretinoid  Idiocy 


561 


account  of  constipation.  In  many  of  these  cases  all  the  evidence  of  cretinism 
consists  in  a  dull  and  heavy  look,  backwardness  in  intelligence,  and  obstinate 
constipation.  In  more  marked  cases  in  infants,  the  tongue  is  large,  the  neck 
short  and  thick,  the  abdomen  excessively  rounded,  the  skin  generally  thick 
and  wrinkled  ;  the  infant  is  certain  to  be  dull  and  stupid,  and  there  is  always 
constipation,  there  being  no  power  to  expel  the  faeces.  No  thyroid  gland  can 
be  felt. 

When  the  child  is  older  the  appearances  are  far  more  striking  and  the 
physiognomy  is  very  peculiar  and  characteristic.  They  are  dwarfs,  being 
stunted  in  growth  :  one  of  our 
own  cases,  that  of  a  boy  aged 
12  years,  measured  34  inches  high 
and  weighed  28  pounds.  In  two 
cases  of  Hilton  Fagge's,  one,  aged 
\^\  years,  was  only  32  inches  high  ; 
another,  20  years  old,  was  only 
28  inches  in  height.  Their  heads 
are  large  and  broad,  often  flattened 
at  the  vertex  ;  the  face  is  broad, 
the  eyes  wide  apart,  the  nose 
flattened,  and  the  lips  are  large  and 
pouting.  The  tongue  is  strikingly 
large  and  thick,  and  sometimes 
hangs  from  the  mouth  ;  the  belly 
is  tumid,  the  umbilicus  protruding 
and  low  down  in  its  position,  the 
lower  limbs  are  disproportionately 
short  as  compared  with  the  body, 
the  gait  is  awkward  and  waddling. 
The  skin  is  coarse  and  thick,  and 
of  a  sallow  colour ;  in  some  the 
subcutaneous  tissues  are  thick  and 
myxoedematous.  Usually  no  thy- 
roid is  present,  or,  if  present,  is 
very  small,  but  in  almost  all  cases 
described  peculiar  fatty  tumours 
are  present  in  the  posterior  tri- 
angles of  the  neck  behind  the 
sterno-mastoid  muscles  and  imme- 
diately above  the  clavicles.  These 
tumours  are  soft,  movable,  and  lobulated 
sterno-mastoid  muscles  and  also  beneath  the  clavicles. 

The  degree  of  intelligence  in  these  cases  differs  :  mostly  they  are  childish 
in  their  ways  rather  than  imbecile.  They  are  late  in  learning  to  sit  up  and 
walk,  and  late  also  in  talking  ;  in  the  worst  cases  they  are  completely 
imbecile.  They  are  mostly  good-humoured  and  easily  controlled.  In  one  of 
our  cases  the  boy  was  employed  by  his  father,  who  was  a  butcher,  to  stand 
outside  the  shop  on  Saturday  nights  and  shout  out  the  price  of  meat.  His 
peculiar  appearance  and  c^uaint  remarks  always  attracted  customers.     Cretins 

O  O 


i 


Fig.  118 


Cretin.     Walter  P.,  aged  4^  years, 
height  31  inches,  weight  28  lbs. 


they  send  processes  behind  the 


562 


Diseases  of  the  Nervous  System 


are  apt  to  suffer  from  tuberculosis  both  of  the  bones  and  internal  organs,  and 
also  from  rickets. 

Fig.  ii8  represents  a  boy  of  45  years,  the  subject  of  ci-etinism.  He  was  never  right 
from  his  birth;  his  brothers  and  sisters  were  healthy.  He  has  never  talked,  only  utters 
grunting  sounds.  Hardly  understands  anything  said  to  him,  but  laughs  if  amused.  The 
skin  is  coarse  and  the  subcutaneous  tissues  thick.  He  has  large  lips  and  tongue  ;  his  hands 
and  feet  are  disproportionatel}'  large.     No  thyroid  gland  can  be  felt ;  the  supraclavicular 


Fig.  119. — ^Walter  P.,  aged  7  years. 


pads  are  present.  He  has  caries  of  the  ethmoid  bone  and  a  chronic  discharge  of  pus  from 
the  left  eye.  He  remained  in  hospital  ten  months,  during  which  time  his  left  e)'eball  was 
excised  on  account  of  suppuration  ;  he  was  treated  for  awhile  with  subcutaneous  injections 
of  a  glycerine  extract  of  sheep's  thyroid,  but  the}'  had  to  be  omitted  from  time  to  time  on 
account  of  subcutaneous  abscesses.  He  was  discharged  improved.  He  was  lost  sight  of 
for  two  years,  when  he  came  under  the  care  of  Mr.  W.  Barker  Bale  in  the  Stockport 
Workhouse  (see  fig.  119)  ;  he  was  treated  with  thyroid  and  greatly  improved  (see  fig.  120). 
We  are  indebted  to  Mr.  Bale  for  the  photographs. 


Cretinoid  Idiocy  563 

All  degrees  of  severity  may  be  met  with  in  congenital  myxcedema,  and 
the  slighter  cases  ai'e  very  apt  to  be  overlooked.  In  the  mild  cases  there 
maybe  little  elseto  note  except  that  the  child  or  the  young  adult  is  a  dwarf ; 
probably  also  there  is  mental  dulness  and  backwardness.  In  exceptional 
cases  sporadic  cretinism  is  associated  with  congenital  deaf-mutism.  In  one 
family  we  know,  the  oldest  child,  a  girl,  is  completely  deaf,  though  there  was 


Fig.  120. — Walter  P.,  aged  8  years,  after  nine  months'  treatment  with 
thyroid  extract. 

apparently  some  hearing  power  during  her  first  two  or  three  years  ;  she 
suffers  from  an  enlarged  and  cystic  thyroid  ;  the  second,  a  boy,  is  partially 
deaf;  the  third,  also  a  boy,  is  a  deaf-mute,  and  suffered  from  sporadic 
cretinism  ;  he  has  greatly  improved  with  thyroid  extract. 

Treatment. — While  thyroid  extract  is  of  the  greatest  value  in  all  forms 
of  congenital  myxoedema  or  '  sporadic  cretinism,'  there  is  good  evidence  to 
show  that  the  earlier  in  life  it  is  taken  the  better  will  be  the  result  of  its  action, 

002 


56"4 


Diseases  of  the  Ahrvous  System 


We  usually  begin  in  3'oung  patients  with  \\  gr.  of  the  dried  sheep's  thja'oid 
glands  given  in  the  form  of  tabloids  dail)',  increasing  to  two  or  three  daily 
according  to  circumstances.  It  is  necessary  to  watch  the  patient  carefully, 
inasmuch  as  the  thyroid  extract  is  a  powerful  remedy,  and  individual 
susceptibility  to  its  influence  differs  considerably.  It  is  important  to 
watch  the  pulse  and  temperature  ;  if  there  is  an  evening  rise  of  two  or 
three  degrees,  it  will  be  well  to  omit  the  drug  for  a  while.  Cretins  for  the 
most  part  have  a  subnormal  temperature,  and  an  evening  rise  of  over  100° 
is  hkely  to  be  due  to  '  thyroidism.'     With  this  evening  fever  there  is  usually 


Fig-  121. — E.  A.  W.,  aged  2  years, 
height  24^  in.,  weight  16  lb.  2  oz. 


Fig.  122. — E.  A.  W.,  aged  4^  years, 
height  33  in.,  weight  3o'5  lb. 


irritability  and  shortness  ot  temper  ;  this  we  have  noticed  again  and  again 
in  hospital  patients.  There  may  be  vomiting,  jaundice,  diarrhoea,  and  marked 
depression  of  the  heart's  action.  Of  these  symptoms  vomiting,  irritability,  and 
fever  are  the  commonest  signs  of  early  thyroidism,  and  should  always  be  taken 
as  danger  signals  and  the  drug  omitted.  In  a  later  stage  there  is  pallor,  and 
faintness  on  exertion  ;  we  have  seen  this  in  one  case  so  marked  that  it  seemed 
likely  a  fatal  result  might  ensue.  We  have  seen  a  continued  depression  and 
tendency  to  fainting  lasting  for  many  weeks.  With  the  continued  adminis- 
tration of  thyroid  extract  and  rapid  growth  which  may  take  place,  the  child 


Cretinoid  Idiocy  565 

is  apt  to  become  thin  and  lim)),  with   a   tendency  to  knock-knees  and  kiteral 
spinal  curvature. 

Under  the  influence  of  moderate  doses  of  thyroid  extract — that  is,  doses  so 
regulated  as  not  to  produce  any  symptoms  of  thyroidism — the  improve- 
ment in  the  patient  is  most  striking.  The  facial  expression  entirely  changes, 
the  dull  heavy  look  disappears  and  is  succeeded  by  a  bright  and  pleasing 
expression,  the  lips  arc  no  longer  thick,  the  tongue  diminishes  in  size.  The 
skin  becomes  soft,  the  abdomen  less  tumid,  and  the  child  begins  to  shoot  up. 
The  change  is  generally  obser\alDle  within  a  few  weeks  of  the  commence- 
ment of  treatment.  Loss  of  weight  occurs  at  first.  With  the  omission  of 
the  thyroid  treatment  there  is  almost  a  certainty  of  a  relapse,  and  we  ha\e 
seen  relapses  frequently  among  out-patients,  though  perhaps  the  patient  has 
not  gone  back  cjuite  to  its  former  condition.  It  is  necessary  to  continue  the 
treatment,  though  the  amount  of  the  drug  may  be  diminished  to,  say,  5  grs.  a 
week,  for  years.  It  can  confidently  be  predicted  in  a  giveu  case,  if  the 
symptoms  of  cretinism  are  present,  that  improvement  will  take  place  under 
the  thyroid  treatment,  but  how  much  improvement  time  only  will  show.  The 
physical  improvement  in  many  cases  outruns  the  mental  improvement, 
the  experience  of  most  being  that  average  mental  power  is  only  excep- 
tionally attained  by  cretins  under  treatment.  But  more  exj^erience  is  requii-ed. 
Unfortunately,  so  many  of  our  patients  among  the  poorer  classes  are  lost 
sight  of  and  do  not  persevere  with  treatment. 


566  Diseases  of  the  Nervous  System 


CHAPTER  XXVI 

DISEASES    OF    THE   NERVOUS   SYSTEISI — {contllUied) 

Spina  Bifida 

Spina  bifida  is  a  congenital  malformation  in  which  there  is  non-union  of 
the  laminae  of  one  or  more  vertebree,  together  with  a  protrusion  of  a  sac 
composed  of  the  spinal  cord  or  its  membranes  through  this  opening.  The 
deformity  may  be  considered  as  due  to  a  failure  of  the  mesoblast  to  interpose 
itself  between  the  spinal  and  cutaneous  epiblast,  with  or  without  lack  of 
coalescence  of  the  medullary  folds  themselves.  The  protrusion  may  occur 
at  any  part  of  the  spine,  and  may  extend  throughout  nearly  its  whole  length  ; 
usually  only  three  or  four  vertebrse  are  involved,  and  the  lumbar  or  sacral 
region  is  the  part  most  commonly  affected.^  Very  rarely  the  bodies  of  the 
vertebrse  are  divided,  and  the  hernia  projects  forwards  or  laterally.  In  some 
instances  there  is  no  protrusion,  though  the  laminse  have  not  united  ('  spina 
bifida  occulta'),  and  occasionally  there  is  more  than  one  hernia. 
Three  kinds  of  spina  bifida  are  recognised  : 

1.  Protrusion  of  the  spinal  membranes  only  :  'spinal  meningocele.' 

2.  Protrusion  of  the  membranes  together  with  the  spinal  cord  and  nerves  : 
'  meningo-myelocele.' 

3.  Protrusion  of  the  membranes  and  cord,  the  central  canal  of  the  latter 
being  dilated  to  form  the  sac  :  '  syringo-myelocele.' 

To  these  should  be  added  the  cases  where  the  medullary  plates  fail  to 
coalesce — '  myelocele  ' — and  the  central  canal  opens  upon  the  surface,  a  con- 
dition incompatible  with  life  for  more  than  a  few  days.  Also  a  meningo- 
cele may  co-exist  with  a  '  syringo-myelocele,'  constituting  a  '  syringo-menin- 
gocele  ;'  and  finally  there  is  '  spina  bifida  occulta.'  ^ 

The  second  kind  of  deformity  is  much  the  most  common,  forming  63  per 
cent,  of  all  the  cases. 

In  the  first  form  the  swelling  is  usually  small,  and  may  protrude  merely 
between  two  almost  normal  spines  ;  the  cavity  of  the  sac  is  the  subarachnoid 
space,  the  swelling  is  often  covered  with  well-formed  skin,  and  paralytic 
complications  are  often  absent. 

The  vertebral  laminae  vary  much  in  development  ;  the  gap  may  be  very 
wide  and  the  laminee  much  stunted,  or  they  may  form  prominent  e\'erted 
borders  to  the  orifice. 

1  Eighty-nine  cases  out  of  125  collected  by  the  Clinical  Society  were  lumbar  or  sacral. 
-   Vide  Bland  Sutton,  Lancet,  February  25,  1888. 


spina  Bifida  567 

The  central  canal  of  the  cord  is  often  dilated  in  the  first  two  forms  as 
well  as  in  the  third,  and  the  position  of  the  cord  in  the  sac  varies  ;  it  maybe 
slung  up  in  the  sac  by  a  sort  of  mesentery,  but  in  any  case  is  very  imper- 
fectly developed,  and  is  occasionally  transfixed  by  a  bony  process  crossing 
the  canal. 

Syringo-myelocele  is  very  rare  ;  the  sac  is  composed  of  spinal  membranes 
plus  the  cord,  and,  the  cavity  being  the  dilated  central  canal,  the  nerves  are 
embedded  in  the  sac  wall  and  do  not  cross  the  cavity.^ 

The  fluid  in  a  spina  bifida  consists  of  98"9  per  cent,  of  water  with  soluble 
salts  and  a  trace  of  sugar,  or  at  least  some  copper-reducing  substance  ;  also 
small  quantities  of  globulin  ;  it  is,  in  fact,  cerebro-spinal  fluid.  Where,  how- 
ever, the  cavity  of  the  sac  is  continuous  with  the  subdural  space,  no  sugar 
will  be  found.- 

In  meningo-myelocele,  the  common  form,  the  sac  is  formed  of  dura 
mater  lined  by  arachnoid  (both  'layers'),  hence  the  cavity  is  the  subarach- 
noid space.  The  spinal  cord  traverses  the  sac  and  blends  with  its  roof;  from 
the  flattened  thinned-out  cord  the  spinal  nerves  arise  and  pass  across  the 
sac  to  their  respective  foramina.  The  surface  of  the  sac  may  be  covered 
entirely  with  skin,  or  may  be  thin  and  transparent,  only  consisting  at  its 
upper  part  of  the  membranes,  or  membranes  covered  with  an  imperfect 
epidermic  layer,  while  at  the  sides  the  skin  is  usually  better  formed.  Some- 
times a  dimple  or  longitudinal  furrow  in  the  middle  line  marks  the  attach- 
ment of  the  cord  and  shows  its  presence  in  the  sac,  an  important  point  in 
the  question  of  treatment.     Sometimes  the  sac  is  loculated. 

The  tumour  resulting  from  spina  bifida  is  median  in  position,  usually 
sessile,  fluctuant,  and  translucent  in  varying  degree,  according  to  the  amount 
of  healthy  skin  covering  it.  Lateral  meningocele  has  been,  however,  met 
with.  The  contents  can  be  partially  reduced  into  the  spinal  canal, 
unless  the  communication  has  been  shut  off  (false  spina  bifida).  The 
surface  not  uncommonly  is  ulcerated,  and  is  sometimes  marked  by 
ntevoid  tissue,  as  in  the  case  of  meningoceles.  The  swelling  becomes  tense 
on  the  child  crying,  and  there  is  often  some  associated  deformity  ;  hydro- 
cephalus, meningocele,  talipes,  harelip,  a  peculiar  webbed  condition  of  the 
thighs  ('siren'),  or  other  deformity  may  coexist,  and  the  subjects  of  spina 
bifida  are  often  marasmic  and  soon  die  ;  in  other  cases,  however,  they  are 
fat  and  hearty.  We  have  seen  them  too  fat,  the  subject  of  a  sort  of  diffuse 
lipomatous  condition  such  as  is  sometimes  seen  in  cases  of  talipes.  On  the 
whole,  paraplegia,  talipes,  and  hydrocephalus  are  the  three  commonest  com- 
plications.    '  Trophic '  ulcers  are  sometimes  seen  on  the  feet. 

Diagnosis. — The  diagnosis  of  spina  bifida  can  only  be  doubtful  where 
there  is  a  complete  skin-covering  to  the  tumour.  In  such  cases  congenital 
sacral,  or  other  tumours — hygroma,  teratoma,  or  lipoma — may  be  mistaken 
for  spina  bifida,  and  the  possibility  of  the  communication  with  the  spinal  cord 
having  been  shut  off  must  also  be  borne  in  mind.  The  presence  of  solid 
masses  in  a  median  tumour  and  the  absence  of  general  fluctuation  would 
1  A  case  of  this  sort  has  been  recorded  by  Morton  in  the  Bristol  Med.  Chir.  Jour., 
March  1892. 

-  A  case  of  this  nature  was  reported  by  Pearce  Gould  in  the  Cliu.  Sue.  Trans.  1882. 
Injection  oured  the  patient. 


568  Diseases  of  the  N'ervotis  System 

point  to  a  teratoma  or  lipoma,  while  a  hygroma  is  more,  spongy,  usually 
flatter,  and  often  not  exactly  median.  The  presence  of  naevus-stains  may 
raise  the  question  of  whether  the  whole  swelling  is  not  njevoid.  The  fixity 
of  the  tumour  to  the  spine,  its  reducibility,  the  possibility  of  feeling  the  edges 
of  the  opening  in  the  laminee,  and  the  coexistence  of  other  deformities  may 
throw  light  upon  a  doubtful  case.  In  some  instances  puncture  with  a  fine 
needle  and  examination  of  the  fluid  drawn  ofi:"  may  be  required  ;  a  highly 
albuminous  fluid  would  be  inconsistent  with  spina  bifida.  Non-congenital 
tumours  cannot,  of  course,  be  confounded  with  spina  bifida.  The  per- 
sistence of  communication  with  the  meningeal  cavities  can  be  determined 
by  variations  in  the  size  of  the  swelling.  The  term  •  false  spina  bifida,' 
usually  limited  to  cases  where  the  sac  no  longer  communicates  with  the  sub- 
arachnoid space,  is  sometimes  applied  to  any  median  congenital  tumour 
along  the  spine. 

Prognosis. — Nearly  all  cases  of  spina  bifida  left  to  themselves  die, 
mostly  from  meningitis  after  rupture  of  the  sac,  or  from  marasmus  ;  some, 
however,  recover  completely,  the  sac  shrinking  up  and  forming  a  mere 
puckered  cicatrix.  Occasionally  spontaneous  cure  takes  place  i7t  ufero, 
and  even  rupture  is  not  universally  fatal.  Cure  of  the  spina  bifida,  it  must 
be  remembered,  does  not  imply  cure  of  paralysis  or  other  complications. 

Treatment. — Though  simple  repeated  tappings,  pressure,  ligature,  and 
excision  have  all  occasionally  proved  successful  in  the  treatment  of  spina 
bifida,  the  Clinical  Society's  report  shows  that  the  safest  and  most  gene- 
rally appHcable  plan  is  that  of  injection,  and  probably  Morton's  fluid  ^  is 
the  best  for  this  purpose.  Either  ligature  or  excision  is  almost  necessarily 
fatal  where  the  case  is  one  of  meningo-myelocele,  and  as  this  is  the  most 
common  form,'-^  and  it  is  impossible  to  be  sure  in  any  given  case  that  a 
simple  meningocele  is  present,  the  plan  is  only  occasionally  applicable.^ 

Treatment  by  injection  is  managed  as  follows  :  The  child  should  be 
held  back  downwards,  and  a  fairly  fine  injecting  syringe  should  be  charged 
with  Morton's  fluid  ;  the  needle  is  then  passed  in  obliquely  through  the  skin 
and  from  fifteen  minims  to  a  drachm  of  the  fluid  injected.  Care  must  be  taken 
that  the  puncture  is  made  through  skin  and  not  through  thin  membrane, 
and  that  it  is  well  away  from  the  middle  line,  both  to  diminish  the  risk  of 
subsequent  leakage  and  to  avoid  injury  to  the  cord  or  nerves.  After  the 
injection,  the  child  must  be  kept  upon  its  back,  the  puncture  sealed  with 
collodion,  the  tumour  packed  well  round  with  absorbent  wool,  and  a  flannel 
bandage  applied.  It  is  perhaps  better  to  withdraw  some  fluid  before  injecting, 
and  the  child  must  be  kept  entirely  in  the  supine  position,  to  prevent  the 
fluid  from  passing  into  the  spinal  canal.  If  the  tumour  does  not  shi-ink  and 
no  ill  effects  follow,  the  injection  should  be  repeated  at  intervals  of  a  fort- 
night. Occasionally  the  tumour  does  not  begin  to  shrink  for  a  month  or  two 
after  an  injection,  as  in  a  case  related  to  us  by  Dr.  Wallace,  of  Longsight. 

1  Iodine  gr.  x,  iodide  of  potassium  gr.  xxx,  gl3'cerine  ji.  The  amount  of  iodine  may 
be  increased  up  to  gr.  xxx. 

-  Prescott  Hewett  found  only  one  case  out  of  twenty  in  which  there  was  no  nerve 
element  in  the  sac. 

■'  Mr.  Mayo  Robson,  of  Leeds,  and  others,  liave  had  some  successful  cases,  but  the  facts 
remain  as  above  stated. 


spina  Bifida 


569 


Injeclion  may  fail  to  produce  any  effect,  may  result  in  immediate  death, 
may  be  followed  by  leakage  or  hydrocephalus  ;  a  single  injection  may 
cure,  or  several  may  be  required.  This  plan  should  be  employed  in  all 
cases  unless  the  child  is  obviously  marasniic  or  dying  from  rupture  of  the 
sac,  or  unless  the  tumour  is  quiescent  and  giving  rise  to  no  trouble  ;  or,  of 
course,  if  it  is  shrinking  spontaneously,  no  treatment  should  be  adopted. 

Sometimes  a  spina  bifida  is  ruptured  at  birth,  or  sloughs  shortly  after- 
wards fi'om  pressure  ;  nothing  can  be  done  for  such  a  case  except  to  dust  it 
over  with  iodoform  and  protect  it  carefully  from  pressure  and  contamination 
with  the  child's  discharges.     We  have  not  seen  a  case  recover  when  the  sac 

has  been  ruptured  in  this  way,  though 
recovery  does  occasionally  occur 
(Maylard).  Superficial  ulceration  is 
less  serious  and  should  be  managed 
in  the  same  way.  Even  if  the  spina 
bifida  is  cured  by  injection,  it  is  not 


^W-^ 


Fig.  123. — A  case  of  cured  Spina  Bifida  (by 
injection)   with  co-existing  Talipes. 


Fig.  124. — Shows  a  section  through  a  Spina 
Biiida  cured  by  injection.  A  small  cavity 
still  remains.  The  child  died  some  time  after 
of  scarlet  fever. 

rare  for  hydrocephalus  to  appear 
later  ;  hence  the  mortality,  direct  or 
indirect,  among  these  cases  is  very 
high. 

As  already  mentioned,  in  certain 
cases  the  sac  becomes  shut  off  from 
the  general  cavity  of  the  membranes  and  the  cyst  remains  without  com- 
munication with  any  important  structures  :  such  result  can  only  occur  in 
meningoceles  ;  the  tumour  then  usually  requires  no  treatment  ;  it  may,  how- 
ever, be  tapped  or  injected  and  excised  with  probably  impunity.  These  cases 
and  sacral  spina  bifida  are  the  ones  most  likely  to  be  successfully  treated  by 
excision. 

In  connection  with  spina  bifida  must  be  mentioned  the  so-called  sacral 
or  coccygeal  dimple  described  by  Lawson  Tait  and  others.  This  is  a 
small  dimple  or  depression  in  the  skin  over  the  lower  part  of  the  sacrum  or 
upper  part  of  the  coccyx  ;  it  can  often  be  obliterated  by  traction  upon  the 
skin.      It  probably  results  from  imperfect  obliteration  of  the  dorsal  furrow. 


570  Diseases  of  the  Nervous  System 

a  sort  of  incomplete  spina  bifida.  Fig.  125  shows  a  more  marked  condition 
of  the  same  thing,  which  was  associated  with  tahpes.  It  has  been  pointed 
out  by  Dr.  Dunlop,  of  Jersey/  that  the  dimple  may  be  associated  with  bending 
back  of  the  coccyx.  Another  view  of  the  ori- 
gin of  this  little  depression,  which  is  quite  com- 
monly to  be  found,  is  that  it  represents  the  '  pos- 
terior umbilicus,'  or  'blastopore.'  It  has  been 
supposed  to  be  the  remains  of  the  neurenteric 
canal.  Congenital  sacral  fistulse  are  a  more 
marked  condition  of  the  same  thing  :  they  may 
cause  trouble  by  retention  of  sebaceous  secretion 
and  require  removal  ;  a  tuft  of  hair  or  '  caudal 
appendage '  has  been  found  in  the  neighbour- 
hood of  these  fistulee  (Terrillon,  Gueniot,  &c.). 
The  case  here  figured  (fig.  125) appears  to  bean 
intermediate  condition  between  the  ordinary 
spina  bifida  and  the  rare  condition  described  as 
'  spina  bifida  occulta,'  in  which  the  laminse  of 
one  or  more  vertebrse  are  deficient,  but  there  is 
no  hernial  protrusion.  In  '  spina  bifida  occulta ' 
the  site  of  the  deficiency  is  marked  by  a  local 
overgrowth  of  hair,  and  there  appears  to  be 
usually  a  coexisting  (resulting)  tendency  to  the 
development  of  perforating  ulcer  of  the  foot  and 
pes  varus.  We  have  noticed  an  overgrowth  of 
hair  and  a  formation  of  ti'ophic  ulcers  in  oases 
of  spina  bifida  cured  by  injection  ;  both  the 
hypertrichosis  and  the  ulcer  developed  only 
Fig.  125.— Slight  sacral  Spina  Bifida  ^yhen  the  tumour  was  more  Or  less  completely 

which  has  undergone  spontaneous  ,  .   .  , 

cure.    The  girl  had  also  Talipes,  shrunken.     In  such  cases  endarteritis  and  neu- 
and  was  mentally  dull.  There  was    j  j    f  ^    affected  foot  have  been  found,  with 

an  ulcer  on  the  dorsum  of  the  foot.    ^''•'•^  ^i    ■.!.  -^  -, 

great'  hypertrophy  of  the  muscular  coat  of  the 
arteries.  In  cases  of  spina  bifida,  both  manifest  and  '  occult,'  paralyses  and 
contractures  of  the  lower  extremities  have  been  relieved  by  operation,  and 
the  removal  of  bands  and  fibrous  or  fatty  masses  pressing  on  the  cord  or 
nerves. 


S^ening'ocele 

Malformations  corresponding  to  spina  bifida  are  not  rarely  met  with  in  the 
head.  The  most  common  form  is  a  hernia  of  the  meninges  forming  a 
meningocele,  the  cavity  of  which  is  the  subarachnoid  space.  In  other 
instances  the  protrusion  contains  brain  substance  as  well — encephalocele, 
or  hydrencephalocele,  or  meningo-encephalocele  ;  the  last  is,  according  to 
Treves,  the  commonest,  and  pure  meningocele  the  rarest  form. 

These  hernige  are  most  common  in  the  occipital  region,  the  protrusion 
taking  place  through  a  median  opening  corresponding  to  the  space  between 
the  centres  of  ossification  of  the  supra-occipital  bone.     In  other  instances  it 

'  Lancet,  May  6,  1882. 


Meningocele 


571 


occurs  al  the  root  of  the  nose,  through  tlic  suture  between  the  frontal  and  nasal 
l)ones,  or  at  one  or  other  angle  of  the  orbit,  or  at  other  parts,'  the  pharynx, 
&c.  The  general  characters  of  these  cysts  need  no  further  description 
licre  ;  they  are  precisely  those  of  a  spina  bifida,  except  that  the  skin  over  a 
meningocele  is  more  often  normal.  The  fluid  is  often  partially  or  wholly 
reducible,  and  its  reduction  may  give  rise  to  pressure  symptoms  ;  the  swell- 
ing becomes  more  tense  when  the  child  cries,  and  is  more  or  less  trans- 
lucent according  to  its  contents,  whether  fluid  or  cerebral.  The  course  of 
these  cases  is  often  the  same  as  that  of  a  spina  bifida  :  the  swelling  grows 
and  ruptures,  and  the  child  dies  ;  sometimes,  however,  the  cyst  shrinks  after, 
or  without,  rupturing. 

Diagnosis. — The  diagnosis  is  in  most  cases  easy  :  the  swelling  is  in  the 
position  of  a  weak  spot  in  the  skull  ;  it  is  congenital.  The  opening  in  the 
skull  can  usually  be  felt,  and  the  other  characters  mentioned  suffice  to  dis- 
tinguish it.  Sometimes,  however,  especially  when  small,  it  is  difficult  or  im- 
possible to  distinguish  meningoceles  from  dermoid  cysts,  or  cysts  connected 
with    na?vi,  especially   as   nttvoid    patches    are  common  on  the  surface  ot 


Fig.  126. — Occipital  Meningocele 


Fig.  127. — Frontal  Meningocele.     Spontaneous  cure,  with 
resulting  deformity  of  the  nose.     (Dr.  Moritz's  case.) 


meningoceles.  Dermoid  cysts  sometimes  cause  perforation  of  the  skull 
beneath  them,  and  hence  are  very  difficult  in  such  cases  to  diagnose  with 
certainty  \  they  are,  however,  usually  more  mobile  and  less  affected  by  pres- 
sure than  meningoceles.  The  deformity  is  often  accompanied  by  idiocy, 
paralysis,  or  spastic  contractures,  and  other  malformations.  In  some  cases 
the  protrusion  may  attain  enormous  bulk,  the  greater  part  of  the  cranial  con- 
tents being  lodged  outside  the  skull.  Most  museums  contain  specimens  01 
this  sort,  which  have,  however,  no  practical  surgical  bearing. 

Treatment. — Unless  the  tumour  is  enlarging,  no  treatment  except  pro- 
tection is  wise  ;  should  anything  be  desirable,  repeated  tappings  or  injection, 
as  in  the  case  of  spina  bifida,  is  the  best  course  for  meningoceles.  Attempts 
have  been  made  to  excise  the  tumours,  with  sufficient  success  to  encourage 
further  trials,  in  selected  cases.  We  have  successfully  excised  an  occipital 
meningocele  in  which  the  tumour  did  not  communicate  with  the  membranes  ; 

1  The  late  Dr.  Carrington  has  recorded  a  case  of  interparietal  hydrencephalocele  [Clin. 
Soc.  Trans.  1881);  and  the  protrusion  sometimes  takes  place  through  the  foramen  mag- 
num (Holmes,  Sf.  George's  Hospital  Reports,  1866)  :  in  this  case  the  cyst  was  loculated. 


572  Diseases  of  tJie  Nervous  System 

but  in  the  operation  the  membranes,  or  at  least  another  sac,  were  opened. 
No  ill  result  followed.  If  excision  is  attempted  the  skin  should  be  as  far  as 
possible  dissected  back  from  the  membranes,  and  the  latter  either  tucked 
into  the  skull  or  removed  and  their  edges  stitched  together.  We  have  also 
excised  an  occipital  meningo-encephalocele  in  which  a  piece  of  the  cere- 
bellum of  the  size  cf  a  walnut  was  removed  ;  the  child  recovered,  though 
it  developed  hydrocephalus  after  the  operation.'  But  we  have  had  two  or 
three  fatal  cases  of  excision  of  meningoceles  since. 

Schatz  reports  favourably  of  the  treatment  of  occipital  meningoceles  by 
puncture  and  pressure,  and  records  a  cure  in  three  cases  by  constriction  of 
the  pedicle  with  clamps.     {Berlm.  Klin.  Woch.  1885,  No.  28,  p.  371.) 

Much  deformity  is  sometimes  produced  by  the  presence  and  shrinkage  of 
a  meningocele  (see  fig.  127,  kindly  given  us  by  our  friend  Dr.  Aloritz). 

Occasionally  meningoceles  protrude  through  the  roof  of  the  pharynx  or 
nasal  cavities  :  in  such  cases  mistakes  as  to  the  nature  of  the  swelling  have 
led  to  speedily  fatal  results  after  operation. - 

Spinal  I^eningitis 

Spinal  meningitis  mostly  occurs  in  its  acute  form  in  association  with 
cerebral  meningitis,  and  in  its  chronic  form  in  connection  with  spinal  caries. 
Acute  cerebro-spinal  meningitis  has  already  been  referred  to  (p.  480),  and 
the  symptoms  of  spinal  meningntis,  Avhen  superadded  to  those  of  cerebral 
meningitis,  discussed.  The  dissociation  of  the  symptoms  of  each  is  not 
easy,  as  cerebral  disease  gives  rise  to  symptoms  closely  resembling  those 
given  by  a  spinal  lesion.  Thus,  basal  meningitis,  especially  when  it  occurs 
low  down  around  the  pons,  medulla,  and  cerebellum,  will  jaroduce  tetanoid 
rigidity  with  spasms  of  the  muscles  of  the  back  and  neck.  A  tumour  of  the 
middle  lobe  of  the  cerebellum  may  produce  acute  pain  referred  to  the  spine 
and  spasm  of  the  erector  spinee  (see  case,  p.  495).  On  the  other  hand,  spinal 
meningitis,  either  tubercular,  simple,  or  purulent,  may  be  found/<7.y^  mortem., 
having  given  no  definite  symptoms  during  life,  certainly  not  those  usually 
associated  with  spinal  meningitis. 

The  most  characteristic  symptoms  of  spinal  meningitis  are  shooting 
pains  down  the  limbs  and  round  the  body,  with  hyperaesthesia  of  the  skin, 
rigors,  quickened  pulse,  and  fever.  There  are  rigidity  about  the  limbs, 
retraction  of  the  head,  and  tenderness  about  the  spine.  The  diagnosis  is 
often  difficult  :  hysteria,  tetany,  and  the  cramps  associated  with  acute 
intestinal  catarrh,  as  well  as  cerebral  meningitis,  may  be  mistaken  for  it. 
Synovitis  of  the  vertebral  joints  may  resemble  meningitis  of  the  cord.  If 
the  spinal  meningitis  pass  into  the  chronic  stage,  paresis  of  the  upper  and 
lower  extremities  may  come  on. 

Spinal  meningitis  is  necessarily  a  disease  which  tends  to  a  fatal  termina- 
tion, but  not  so  certainly  as  cerebral  meningitis  :   certainly,  cases  diagnosed 

1  Mr.  Jessop,  of  Leeds,  also  records  a  successful  case  of  excision,  but  there  was  no 
distinct  communication  with  the  interior  of  the  skull ;  hence  it  has  little  bearing  on  the 
general  question — Brit.  Med.  Jour.  December  30,  1882. 

-  For  tables' as  to  the  frequency  of  different  varieties,  &c.  vide  Treves'  Manual  u 
Surgery,  vol.  ii. 


spinal  Meningitis — Paraplegia  573 

as  spinal  meninyitis  recover.      Cases  such  as  the  following  are  not  altogether 
uncommon  : 

A  girl  aged  13  years  complained  six  days  before  admission  of  pain  in  the  back  ;  her 
licad  was  drawn  bacl<,  she  could  not  sleep  for  the  pain.  On  admission  she  was  evidently 
acutely  ill ;  she  lay  on  her  side  in  bed,  with  her  legs  drawn  up,  and  there  was  great  retrac- 
tion of  the  head  ;  there  was  much  pain  along  the  spine,  aggravated  on  movement ;  pain 
shooting  along  the  arms  was  complained  of  ;  the  pulse  Vvas  108,  the  temperature  varied 
from  98^  to  102°  Fahr.  -She  was  given  chloral  hydrate,  and  an  ice-bag  was  applied  to  the 
spine  ;  for  five  or  six  davs  she  continued  acutely  ill,  the  temperature  varying  from  97°  to 
102'^  ;  there  were  se\-eral  rigors  on  succeeding  days  :  the  head  was  retracted,  any  forcible 
movement  forward  caused  pain,  there  was  exaggerated  knee-jerk,  and  ankle-clonus  was 
present.  The  svmptoms  gradually  subsided  about  a  week  after  admission,  leaving  her 
very  weak  and  emaciated.      In  six  weeks  she  was  discharged  well. 

Such  cases  may  be  open  to  the  suspicion  that  the  inflammatory  lesion 
present  was  in  the  vertebral  joints  or  spinal  muscles  rather  than  in  the 
spinal  canal  ;  but,  on  the  other  hand,  none  of  the  other  joints  or  muscles 
were  affected,  and  there  is  no  reason  why  a  spinal  meningitis  should  not 
occur  and  get  well  again.  A  case  in  which  laminectomy,  incision,  and  drainage 
of  the  theca  was  done  successfully  is  recorded  by  Rolleston  and  AUingham 
in  the  '  Lancet'  of  April  i,  1899. 

Treatme)tt. — Rest  in  bed,  in  perfect  quietness,  is  essential.  Ice  to  the 
spine  is  probably  the  best  local  application  that  can  be  used.  The  pain 
must  be  relieved  by  small  morphia  injections,  or  opium  may  be  given  by  the 
mouth.     Instead  of  opium,  bromides  and  chloral  may  be  first  tried. 


Farapleg°ia 

By  far  the  commonest  cause  of  paraplegia  during  childhood  is  compres- 
sion of  the  cord  from  caries  of  the  bones  of  the  vertebrse  ;  in  rare  cases  the 
cord  is  compressed  by  a  tumour,  growing  from  the  sheath  of  the  cord.  Other 
forms  of  paraplegia  occur  which  may  be  due  to  myelitis,  following  measles 
or  other  zymotic  disease,  an  acute  atrophic  paralysis  affecting  both  legs,  and 
some  other  anomalous  paralyses  of  uncertain  origin.  There  is  also  the 
spastic  paralysis  of  cerebral  origin  and  hysterical  paraplegia. 

Compression  of  the  Cord  from  Spinal  Caries. — It  is  important  to  bear 
in  mind  that  the  paraplegia  which  occurs  in  association  with  caries  of  the 
spine  is  less  often  due  to  direct  pressure  from  the  deformity  produced  by  the 
falling  together  and  bending  of  the  vertebrae  than  to  the  inflammatory  pro- 
ducts which  are  thrown  out  around  the  cord.  We  may  therefore  have  a 
paraplegia  without  the  slightest  external  deformity  of  the  spine,  and,  more- 
over, a  perfect  recovery  may  issue  in  a  given  case  by  absorption  of  the  in- 
flammatory products — a  result  that  could  hardly  be  expected  if  the  compression 
was  due  to  the  direct  pressure  of  a  bent  spine.  The  inflammatory  process 
which  commences  in  the  body  of  a  vertebra  is  apt  to  spread,  so  that  lymph  or 
curdy  pus  is  effused  outside  the  dura  mater,  between  the  latter  and  the  bone, 
or  inside  the  dura  mater,  and  the  cord  is  compressed,  or  the  cord  may  also 
be  affected  by  the  inflammatory  process.  Pressure  on,  and  inflammatory 
changes  in  the  cord  itself  ma}'  take  place  at  any  part  of  the  cord — cervical, 
dorsal,    or  lumbar    region.     Pressure  is  also   exceedingly  likely   to   affect 


574  Diseases  of  the  Nervous  System 

some  of  the  nerves,  the  latter  being  surrounded  and  compressed  by  inflam- 
matory products  as  they  pass  through  the  dura  mater  and  foramina. 

Symptoms. — Symptoms  of  compression  of  the  cord  or  its  branches  may 
come  on  early  or  late  in  the  disease.  In  the  majority  of  cases  the  early  sym- 
ptoms are  those  connected  with  deformity  of  the  spine  and  perhaps  irritation  of 
the  sensory  nerves,  and  it  is  only  late  in  the  disease,  when  the  deformity  has 
been  well  marked  for  many  months,  that  symptoms  of  pressure  on  the  cord 
supervene.  In  the  minority  of  cases  it  is  the  weakness  and  paresis  of  legs 
with  exaggerated  knee-jerk  that  suggest  the  onset  of  spinal  caries.  It  is  im- 
portant to  bear  in  mind  that  a  paraplegia  may  exist  for  many  months 
without  any  deformity  of  the  spinal  column  being  present,  the  latter  eventually 
supervening,  and  explaining  the  cause  of  the  paraplegia  which  had  remained 
in  doubt.  Gowers  mentions  the  case  of  a  patient  who  had  complete  para- 
plegia for  six  months  ;  an  experienced  surgeon  who  examined  him  was 
unable  to  detect  the  existence  of  spinal  caries,  and  yet  a  few  months  later 
undoubted  symptoms  of  bone  disease  appeared. 

The  motor  paresis  usually  comes  on  gradually  :  the  child  is  weak  upon 
its  legs,  quickly  tiring,  and  supports  itself  whenever  possible  by  the  help  of 
chairs  or  tables.  When  the  dorsal  cord  is  compressed  the  reflexes  are 
exaggerated  ;  if  the  sole  of  the  foot  is  tickled  as  the  child  lies  in  bed  the  foot 
is  sharply  withdrawn  ;  if  the  knee  is  bent  by  holding  the  ankle  in  the  operator's 
hand,  a  sharp  tap  on  the  patellar  tendon  gives  rise  to  an  exaggerated  '  knee- 
jerk  ; '  ankle-clonus  can  usually  be  readily  obtained.  Gradually  a  spastic 
paraplegia  comes  on  :  the  child  cannot  walk,  or  later  cannot  stand,  without 
help,  and  when  lying  down  in  bed  the  knees  tend  to  draw  up  and  the  feet  to 
be  extended  in  consequence  of  the  rigidity  of  the  calf  muscles.  Usually 
there  is  no  loss  of  sensation.  The  sphincters  may  be  affected,  and  bladder 
troubles  may  ensue  if  the  lumbar  cord  become  involved  by  descending 
inflammation.  Prior  to  the  onset  of  motor  or  cord  symptoms,  there  may  be 
various  shooting  pains  experienced  along  the  intercostal  nerves  ;  children 
with  commencing  caries  of  the  spine  will  complain  of '  belly-ache '  or  refer 
the  pain  to  the  pit  of  the  stomach  or  sternum.  Thus  pain  referred  to 
the  umbilicus  suggests  that  there  is  irritation  of  the  tenth  dorsal  nerves 
(eighth  dorsal  vertebrae),  or  pain  at  the  ensiform  cartilage  to  the  sixth  and 
seventh  nerves  (fourth  and  fifth  dorsal  vertebrae),  or  over  the  thorax  to  the 
upper  dorsal  nerves.  There  may  be  hypersesthesia  or  ansesthesia  of  the 
skin. 

When  the  cervical  region  of  the  cord  suffers  the  symptoms  are  apt  to  be 
more  marked  than  when  the  dorsal  region  is  affected  ;  there  may  be  pains 
shooting  down  the  arms,  shoulders,  neck,  and  scalp,  according  to  the  position 
of  the  lesion  ;  hypersesthesia  and  later  ansesthesia  of  the  skin.  The  sensation 
of  pins-and-needles  is  often  complained  of.  There  is  gradual  loss  of  power 
in  one  or  both  arms,  and  wasting  of  the  muscles.  The  shoulder  muscles, 
serratus,  flexors  of  the  elbow  and  supinators  are  affected  when  the  fifth  and 
sixth  nei'ves  are  involved ;  the  extensors  of  the  wrist  and  fingers  when  the  sixth 
and  seventh  ;  and  the  extensors  of  the  elbow,  flexors  of  the  wrist  and  fingers, 
and  pronators,  when  the  seventh  and  eighth  are  involved.  A  spastic  para- 
plegia inay  come  on,  as  in  disease  of  the  dorsal  cord. 

When  the  lumbar  enlargement  is  compressed,  or  its  branches    there  is 


Parapleg  ia — Myelitis  575 

paraplegia,  the  reflexes  are  not  exaggerated,  l)ut  are  abolished,  and  no 
knee-jerk  can  be  obtained — that  is,  if  the  pressure  is  severe  enough  to  interfere 
with  the  functional  activity  of  the  grey  matter  of  this  region.  The  sphincters, 
both  of  the  bladder  and  rectum,  are  likely  to  become  paralysed  if  a  compres- 
sion myelitis  of  the  lumbar  cord  takes  place. 

The  course  of  the  disease  varies  exceedingly,  and  depends  upon  the  extent 
and  chronicity  of  the  inflammatory  processes  in  the  bones.  Recovery  from 
the  paralysis  may  take  place  after  the  patient  has  been  bed-ridden  and  help- 
less for  many  months  and  even  years,  and  where  recovery  was  hardly  thought 
to  be  possible.  On  the  other  hand,  the  progress  may  be  from  bad  to  worse, 
there  being  a  gradually  extending  myelitis,  so  that  the  sphincters  become 
paralysed  and  the  patient  suffers  from  incontinence  of  both  urine  and  faeces. 
Sensation  may  become  impaired,  and  the  patient  at  last  dies  of  exhaustion  or 
the  results  of  cystitis,  or  not  infrecjuently  of  tuberculosis  or  lardaceous  disease. 
For  treatment  see  Disease  of  Spine. 

IVEyelitis. — By  far  the  commonest  inflammatory  lesion  of  the  cord  in 
children  is  that  form  which  is  localised  in  the  grey  matter  of  the  anterior 
horns,  which  has  received  the  misleading  name  of  '  infantile  paralysis.' 

An  acute  transverse  myelitis  occurs  in  children  as  well  as  in  adults,  but 
it  is  apparently  less  common.  Disseminated  or  focal  myelitis  appears  some- 
times to  occur  during  some  of  the  zymotic  diseases,  as  typhoid  fever, 
influenza,  measles.  Transverse  myelitis  is  rare  before  the  age  of  ten  years  ; 
it  seems  mostly  to  follow  exposure  to  cold  or  accidents  such  as  occur  to 
schoolboys  in  the  football  field.  In  one  of  our  cases,  that  of  a  boy  of  eight 
years  of  age,  it  followed  paddling  in  the  water.  It  is  very  probable  that 
'catching  cold'  or  an  '  accident'  is  only  the  predisposing,  the  effective  cause 
being  a  toxine  formed  by  the  action  of  micro-organisms. 

The  symptoms  are  much  the  same  as  in  adults  ;  the  ultimate  chance  ot 
recovery  is,  however,  greater,  as  the  cord  seems  to  recover  itself  more  readily 
in  early  life  than  in  later  years.  There  is  usually  a  feeling  of  '  pins-and- 
needles '  in  the  feet,  and  sometimes  rheumatoid  pains  followed  by  loss  of  mus- 
cular power.  At  first  this  may  be  slight,  but  after  a  few  hours  it  becomes  more 
marked,  and  within  twenty-four  or  forty-eight  hours  it  has  reached  its  height. 
There  is  loss  of  sensation  as  well  as  motion,  varying  in  extent  according  to 
the  length  of  cord  affected.  There  is  also  incontinence  of  urine  and 
faeces  ;  if  the  lesion  is  above  the  lumbar  enlargement,  the  sphincters  con- 
tract normally,  but  the  control  exercised  by  the  will  is  cut  off.  The  com- 
monest part  of  the  cord  to  be  affected  is  the  dorsal  region  ;  often  there  is 
some  feverishness. 

All  degrees  of  motor  and  sensory  paralysis  maybe  present.  In  severe 
cases  almost  all  power  is  lost  and  the  legs  fall  about  in  a  helpless  wav, 
though  usually  some  power  of  movement  is  retained  in  the  toes.  The 
reflexes  may  be  completely  absent.  After  a  variable  period,  if  the  lesion  is 
above  the  lumbar  enlargement,  the  reflexes  return  and  become  excessive  ; 
there  is  ankle-clonus,  the  knee-jerk  is  abnormally  vigorous,  and  a  condition 
of  spastic  paraplegia  comes  on.  Sensation,  if  it  has  been  absent,  usually 
returns  before  recovery  of  motor  power. 

The  amount  of  recovery  which  takes  place  is  ^'ariable  ;  we  have  seen 
complete   recovery  eventually  ensue  in  cases  where,  from  the   amount  of 


5/6  Diseases  of  the  Nervous  System 

motor  and  sensory  paralysis  present  in  the  first  instance,  we  had  not  thoug^ht 
it  possible.  Many  months  in  bed  are  necessary  to  effect  this  ;  the  intense 
spastic  paralysis  gradually  lessens  and  may  eventually  disappear. 

If  the  lumbar  enlargement  is  affected,  not  only  is  there  complete  motor 
paralysis,  but  the  muscles  waste  rapidly,  the  rectal  sphincter  is  completely 
relaxed,  and  the  urine  dribbles  away  from  paralysis  of  the  sphincter  of  the 
bladder. 

If  the  cervical  enlargement  is  affected,  the  arms  are  paralysed,  the  pupils 
may  be  dilated,  and  death  is  apt  to  ensue  from  interference  with  the  nerve 
supply  to  the  muscles  of  respiration. 

As  an  instance  of  a  transverse  myelitis  occurring  in  the  cervical  region, 
followed  by  partial  recovery,  the  following  case  may  be  related  : 

Trcmsverse  Myelitis. — A  healthy  boy  when  a  year  old  was  exposed  to  cold  by  lying  on 
the  damp  grass  ;  he  woke  crying  during  the  following  night,  the  parents  thinking  he  had 
pain  in  the  stomach  ;  he  was  not  convulsed  ;  next  morning  both  his  arms  and  legs  were 
limp  and  useless,  he  could  not  move  them  or  sit  up  ;  there  was  no.  facial  paralysis. 
Recovery  gradually  took  place,  the  arms  recovering  completely,  the  legs  partially.  When 
seen  at  two  years  of  age,  the  arms  had  completely  recovered,  but  both  legs  were  weak,  so 
that  he  could  not  bear  his  weight  on  them,  but  could  crawl,  dragging  them  after  him  ; 
sensation  seemed  impaired  in  the  legs,  there  was  ankle-clonus  and  exaggerated  tendon 
reflex.  The  child  was  perfectly  intelligent,  and  was  well  nourished,  but  the  muscles  of  the 
leg  were  somewhat  flabby.     He  has  since  been  lost  sight  of. 

As  instances  of  what  were  probably  cases  of  subacute  myelitis,  one  occur- 
ring after  measles  and  another  after  what  was  said  to  be  a  '  cold,'  we  may 
mention  the  following  cases  : 

Myelitis  following  Measles. — -Gertrude  H.,  aged  4  years,  was  quite  well  till  she  con- 
tracted measles  in  August  1882  ;  when  convalescent  it  was  noticed  she  could  not  stand  by 
herself.  She  remained  bedridden  till  admitted  to  the  hospital  in  December.  At  this  time 
she  could  not  bear  the  weight  of  her  body  without  help  ;  the  knee-jerk  was  exaggerated, 
the  front-tap  contraction  was  present,  there  was  no  ankle-clonus.  She  slowly  improved, 
and  by  February  1883  she  could  stand  alone  and  walk  with  help,  throwing  her  legs  forward. 
She  finally  entirely  recovered  after  some  months. 

Myelitis. — George  C,  aged  13  years,  was  quite  well  till  May  1882,  when  he  caught  a 
cold  and  had  a  feverish  sore  throat ;  after  this  his  legs  became  weaker,  though  he  could 
always  walk  with  help.  He  was  admitted  September  1882  ;  his  legs  were  both  weak,  but 
he  could  walk,  swaying  from  side  to  side,  bending  both  knees  very  much  ;  no  loss  of  sehsa- 
-tion,  muscles  react  normally  to  both  continuous  and  faradic  currents;  knee-jerk  exagge- 
rated, the  slightest  touch  producing  a  jerk  ;  there  was  no  evidence  of  any  spinal  disease. 
He  remained  much  in  the  same  condition  till  January  1883,  when  he  went  home.  He 
finally  completely  recovered,  after  attending  as  an  out-patient  for  some  months. 

It  is  difficult  to  account  for  the  symptoms  in  these  two  cases  except  on  the 
supposition  that  they  suffered  from  either  compression  or  disseminated 
myelitis,  which  eventually  got  well. 

Dr.  Thos.  Barlow  records  a  fatal  case  of  disseminated  myelitis  ^  occurring 
during  an  attack  of  measles,  which  proved  fatal  on  the  eleventh  day  of  the 
disease.  He  quotes  two  cases  of  children,  aged  two  years  and  three  years 
respectively,  who  suffered  from  paralysis  apparently  due  to  myelitis  when 

1  'On  a  case  of  early  disseminated  myelitis  occurring  during  measles.' — Dr.  Thos. 
Barlow,  Proc.  of  the  Royal  Med. -Chir.  Soc,  vol.  ii.  p.  146. 


Landry's  Paralysis  577 

convalescent  from  measles.  We  have  seen  several  similar  cases  of  paralysis 
apparently  due  to  myelitis  following  measles  ending  in  recovery. 

Landry's  Paralysis,  or  acute  ascending  paralysis,  is  said  to  occur 
occasionally  in  children  ;  the  following  case  in  many  respects  resembled  this 
form  as  it  occurs  in  adults  : 

Edward  M'L.,  aged  ii  years,  had  good  health  till  January  1881,  when  he  became  ill 
from  the  effects  of  cold  ;  in  a  few  days  he  became  drowsy  and  had  twitchings  in  the  legs, 
which  were  said  by  a  doctor  to  be  due  to  St.  Vitus's  dance ;  the  movements  ceased  and 
left  his  legs  paralysed  ;  eight  days  afterwards  he  lost  the  use  of  his  arms,  and  he  com- 
plained of  pain  in  the  head  and  was  delirious  for  a  week  ;  the  weakness  in  the  arms 
improved,  but  got  worse  again.  When  admitted  in  March  1881  his  arms  were  weak,  he 
moved  his  legs  witli  difficulty,  could  just  manage  to  raise  them  in  bed  ;  no  loss  of  sensa- 
tion ;  the  knee-jerk  was  almost  absent ;  no  ankle-clonus.  He  gradually  improved,  so 
that  by  April  he  was  able  to  walk  without  difficulty,  but  swayed  to  and  fro.  He  finally 
completely  recovered.  It  is  possible  that  this  case  was  in  reality  one  of  peripheral  neuritis 
rather  than  any  spinal  lesion. 

Treatment. — Perfect  rest  in  bed  is  of  the  greatest  importance  in  the 
inflammatory  stage,  all  movements  and  excitation  of  the  spinal  cord  being 
avoided  as  much  as  possible.  The  patient  should  lie  on  his  side  or  his  face 
in  preference  to  his  back,  so  that  the  spine  should  not  be  the  most  dependent 
part.  Of  local  applications  the  spmal  ice-bag  is  probably  the  best,  though 
some  prefer  the  application  of  moist  heat  with  counter-irritation,  such  as 
mustard  poultices,  so  as  to  redden  the  skin.  Probably  there  are  no  medicines 
which  can  control  or  moderate  the  inflammatory  lesion.  Aconite,  ergot,  the 
bromides,  have  all  been  used  with  varying  success.  Both  mercury  and  iodide 
of  potassium  have  also  been  prescribed. 

Great  care  must  be  taken  to  prevent  bedsores  :  perfect  cleanliness  must 
be  observed,  and  pressure  taken  off  any  spot  where  the  skin  becomes  red. 
The  incontinence  of  urine  and  faeces  is  always  a  source  of  difficulty,  as  the 
urine  and  damp  bed-linen  fret  the  skin  and  give  rise  to  sores.  The  best 
position  for  the  patient  is  on  his  face,  so  that  the  urine  as  it  dribbles  away 
may  be  received  into  a  bed-pan.  Boric  or  iodoform  cotton  wool  may  be  used 
to  surround  the  genitals  and  absorb  the  discharges.  If  there  is  retention  of 
urine,  the  catheter  must  be  used.  No  good  can  be  expected  from  the  appli- 
cation of  the  faradic  or  galvanic  current  in  the  early  or  inflammatory  stages  ; 
indeed,  harm  may  not  improbably  be  done  by  exciting  and  frightening  the 
child.  The  more  at  rest  the  cord  is  allowed  to  remain,  the  better  chance  is 
there  of  absorption  of  the  inflammatory  material  and  recovery  of  function  of 
nerve  elements. 

In  the  chronic  stage  good  may  be  done  by  gentle  friction  applied  to  the 
muscles,  and  by  the  application  of  blisters  or  the  actual  cautery  over  the 
region  corresponding"  to  the  disease.  A  change  to  the  seaside,  the  patient 
being  wheeled  out  in  the  open  air  in  a  recumbent  position,  is  likely  to  expedite 
recovery  by  improving  the  general  health. 

Hereditary  Ataxic  Parapleg^ia,  or  Friedreich's  Disease,  is  the  name 
given  to  a  form  of  ataxia  which  commences  for  the  most  part  during  early 
life,  and  which  tends  to  aftect  several  members  of  the  same  family.  It  most 
commonly  appears  during  the  period  of  the  second  dentition  or  from  that  on 
to  puberty.  The  most  characteristic  feature  of  the  disease  is  a  reeling  gait, 
the  patient  swaying  about  both  in  walking  and  standing,  a  condition  made 

P  P 


578  Diseases  of  the  Nervous  System 

more  apparent  by  the  closure  of  the  eyes.  As  in  other  forms  of  ataxy,  the 
knee-jerk  is  quickly  lost.  Failure  of  muscular  power  takes  place  as  the 
disease  progresses.  The  muscles  of  the  head  and  neck  as  well  as  the  arms 
become  affected  mostly  with  tremor,  so  that  when  a  voluntary  movement  is 
attempted  irregular  jerky  movements  take  place.  Nystagmus  is  a  common 
symptom.  The  progress  of  the  disease  is  very  slow.  The  lesion  in  the 
cord  consists  of  sclerosis  of  the  posterior  and  lateral  columns  ;  the  anterior 
column  may  also  be  affected.^ 


Anterior  Polio-myelitis.     Acute   Atrophic  Paralysis. 
*  Infantile  Paralysis  ' 

Etiology. — The  disease,  which  is  usually  known  by  the  name  of  '  in- 
fantile paralysis,'  occurs  most  frequently  during  early  childhood  ;  but,  as  a 
form  of  paralysis  exactly  similar  occurs  during  the  later  years  of  childhood 
and  also  during  adult  life,  the  name  certainly  ought  to  be  abandoned.  It 
most  frequently  occurs  during  the  first  three  years  of  life,  at  least  four-fifths 
of  the  cases  occurring  at  this  period  (Gowers).  It  is  less  frequent  during  the 
first  six  months  than  it  is  during  the  last  half  of  the  first  year  and  during 
the  second.     It  is  by  no  means  a  rare  disease  in  older  children. 

Very  little  is  known  as  to  its  cause,  and,  while  it  occurs  both  in  the  strong 
and  weakly,  in  the  majority  of  cases  in  our  experience  it  has  been  met  with 
in  typically  healthy  children,  with  a  good  family  history,  and  who  could  not 
be  said  to  ail  anything  ;  and  no  reason  could  be  assigned  for  its  onset.  It 
certainly  appears  to  be  commoner  during  the  warm  quarter  of  the  year  than 
at  any  other  period.  It  appears  occasionally  to  follow  exposure  to  cold, 
such  as  sitting  on  damp  grass,  or  it  may  apparently  result  from  an  injury*. 
It  follows  occasionally  as  a  sequela  of  measles,  scarlet  fever,  typhoid, 
pneumonia,  and  acute  diarrhoea.  Dentition  has  been  credited  with  being  a 
cause,  but  of  this  there  is  not  sufficient  evidence.  Perhaps  the  most  likely 
predisposing  cause  is  over-exertion  in  children  who  have  only  recently  learnt 
to  use  their  legs,  though  this  can  hardly  be  a  cause  in  children  under  a  year 
old.  There  has  been  a  growing  belief  during  the  last  few  years  that  the 
inflammatory  lesion  in  the  cord  is  due  to  the  action  of  toxines  produced  by 
micro-organisms.  No  specific  micro-organism  has  at  the  present  time  been 
isolated  ;  the  evidence  of  the  bacterial  origin  of  this  disease  rests  upon  the 
fact  that  in  rare  cases  limited  epidemics  have  been  observed,  and  that  other 
diseases — such  as  posterior  basal  meningitis,  tetanus,  and  diphtheritic  paralysis 
— are  due  to  toxines  formed  by  bacterial  action.  Epidemics  have  been  de- 
scribed by  Medin,  W.  Pasteur,  Buzzard,  and  others,  but  it  is  a  noteworthy 
fact  that  in  some  of  the  cases  neither  the  symptoms  nor  the  post-niorteni 
findings  exactly  corresponded  with  typical  cases  of  anterior  polio-myelitis.  It 
is  important  to  note  that  some  of  the  patients  suffered  from  the  prevailing 
fever,  but  not  from  paralysis.  In  a  case  of  our  own  recorded  below  there 
was  a  feverish  attack  from  which  the  patient  recovered,  followed  by  a  similar 
attack,  associated  with  paralysis  of  one  leg. 

1  See  Gowers,  Diseases  of  the  Nervous  System,  vol.  i.  ;    and  J.  S.  Bury,  Brain,  July 


Ac7ite  Atrophic  Paralysis  579 

Syinpfoins. — The  course  of  the  disease  may  be  conveniently  divided  into 
stages,  and,  following  Gowers,  they  may  be  stated  thus  : 

I.  An  initial  stage,  during  which  the  paralysis  occurs,  usually  pre- 
ceded or  accompanied  by  fever,  and  lasting  a  few  hours  to  a  week.  2.  A 
stationary  period,  which  lasts  from  a  week  to  a  month.  3.  A  period  of 
'regression,'  during  which  the  paralysis  disappears  in  certain  of  the  affected 
muscles,  leaving  others  still  paralysed  ;  this  stage  usually  occupies  one  to 
six  months.  4.  A  chronic  stage,  during  which  atrophy  occurs  and  deformities 
and  contractures  are  developed.  Some  improvement  may  take  place  during 
this  stage. 

I.  The  initial  stage  is  usually  ushered  in  with  fever,  restlessness,  con- 
vulsions, muscular  twitchings,  and  cerebral  disturbance.  The  severity  of  the 
attack  differs  much  in  different  cases  ;  it  has  rarely  been  closely  observed, 
being  usually  attributed  to  dentition  or  gastric  disorder,  and  only  when  the 
paresis  has  supervened  has  the  importance  of  the  attack  been  recognised. 
The  pyrexia  is  rarely  high,  perhaps  101°  to  102°  ;  there  may  be  muscular 
twitchings  of  the  face  or  the  affected  limb  ;  drowsiness,  delirium,  or  convul- 
sions may  be  present.  The  acute  attack  may  be  entirely  absent,  or,  what  is 
more  likely,  ill-defined,  so  that  it  is  overlooked  by  the  friends,  and  the  only 
history  obtained  is  that  the  child  was  put  to  bed  well,  and  that  in  the  morn- 
ing a  limb  or  limbs  were  found  powerless  and  limp.  The  paralysis  is  usually 
first  noticed  after  the  acuteness  of  the  attack  has  passed,  and  in  infants  it  is 
very  likely  to  be  overlooked  at  first,  or  thought  to  be  due  to  weakness  only. 
The  paralysis  reaches  its  height  at  once,  or  at  any  rate  in  a  few  days  or 
under  a  week.  It  is  difficult  to  say  what  proportion  of  cases  die  in  this  stage, 
for  probably  the  nature  of  the  disease  would  hot  be  recognised,  and  the 
attack  would  be  attributed  to  '  convulsions '  or  the  early  stage  of  some  acute 
disease.  Nevertheless,  such  cases  have  been  recorded,  and  lesions  found  in 
the  grey  matter  of  the  spinal  cord. 

It  sometimes  happens  that  two  members  of  a  household  are  attacked 
with  fever,  &c.,  one  gets  well  and  the  other  is  seized  with  characteristic 
'infantile  paralysis'  affecting  some  group  of  muscles.  In  other  instances 
two  or  more  members  of  a  household  within  a  few  days  of  one  another  suffer 
from  attacks  associated  with  paralysis  of  the  anterior  polio-myelitis  type. 

There  seems  to  be  no  relation  between  the  severity  of  the  initial  attack 
and  the  extent  of  the  paralysis  which  follows  it,  some  of  the  most  extensive 
and  severe  paralyses  being  accompanied  by  hardly  any  febrile  disturbance. 
It  is  not  certain  whether  the  febrile  symptoms  are  due  to  the  inflamma- 
tory lesion  taking  place  in  the  cord,  or  if  the  lesion  in  the  cord  as  well  as  the 
fever  and  convulsions  are  the  result  of  some  unknown  process  going  on  in 
the  body. 

In  some  cases  there  is  an  acute  attack,  which  passes  away,  leaving  no 
definite  paresis  :  another  similar  attack  follows,  and  when  this  clears  up  a 
paralysis  is  noted.  This  was  the  case  in  the  following  instance.  A  boy 
aged  two  years,  a  patient  of  Dr.  Sutcliffe  of  Stalybridge,  was  quite  well  and 
running  about,  when  one  day  he  was  taken  suddenly  ill,  crying,  vomiting,  and 
feverish  ;  the  following  evening  he  was  convulsed  ;  he  w^as  put  to  bed  and 
continued  ill  for  two  or  three  weeks  with  apparently  some  brain  trouble  ;  this 
attack  left  him  very  weak ;  but  he  gradually  recovered  and  was  able  to  run 

p  p  2 


580  Diseases  of  the  Nervous  System 

about  again.  He  continued  well  foi'  two  months,  when  the  same  symptoms 
returned  ;  he  cried  with  pain,  there  was  vomiting  and  fever,  followed  by  con- 
vulsions ;  he  remained  ill  for  fourteen  days,  and  just  as  he  was  getting  up 
and  about  again  it  was  noticed  that  his  right  leg  was  paralysed.  When  seen 
two  months  after,  there  was  wasting  and  paresis  of  the  right  buttock,  thigh, 
and  dorso-extensors  of  the  foot. 

\Vliile  in  typical  cases  there  is  more  or  less  complete  loss  of  motor  power 
without  the  sensory  nerves  being  affected,  yet  it  sometimes  happens  there  is 
severe  pain,  and  in  rarer  instances  anesthesia.  It  is  certain  in  these  exceptional 
cases  the  lesion  is  not  absolutely  confined  to  the  anterior  horns.  There  may 
be  severe  shooting  pains  before  the  onset  of  the  paralysis,  or  the  pains  may 
remain  and  there  may  be  hyperaesthesia  or  pain  in  handling  the  limb.  Such 
cases  readily  pass  muster  as  'hysterical,'  especially  in  girls,  but  the  definite 
paralysis  which  remains  makes  the  diagnosis  only  too  certain.  The  following' 
case  of  severe  anterior  polio-myelitis  commenced  with  severe  pain  : 

Alice  D.,  set.  loi  years.  Quite  well  till  October  1896,  when  she  had  two  boils  on  her 
back  which  troubled  her  a  good  deal.  On  October  31  she  did  not  feel  well  and  had  head- 
ache ;  the  next  &a.y  she  was  seized  with  violent  pains  in  the  back,  arms,  and  legs,  and 
had  a  temperature  of  103°  ;  this  continued  for  three  da3's,  when  it  was  noticed  there  was 
almost  complete  loss  of  power  in  her  back,  arms,  and  legs  ;  the  pain  was  worst  in  the  legs, 
making  her  scream  loudly.  She  gradually  regained  power  in  her  back  and  arms,  so  that 
she  can  sit  up  and  feed  herself  ;  the  left  leg  remained  completely  paralysed  from  the  rotators 
of  the  hip  downwards,  the  right  leg  has  regained  slight  power. 

In  another  case  seen  with  Dr.  Sheldon  of  Macclesfield,  a  girl  of  10  years 
had  an  indefinite  febrile  attack,  folloAved  during  convalescence  by  loss  of 
power  in  the  muscles  of  the  right  hip  ;  there  was  some  pain  complained 
of,  and  there  was  hypersesthesia.  The  paresis  of  the  muscles  affected  was 
permanent. 

2.  After  the  paralysis  has  reached  its  fullest  extent,  a  period  during  which 
the  paresis  of  the  muscles  is  stationary  ensues,  varying  from  two  weeks  to 
six  weeks  or  two  months.  At  this  time  the  affected  muscles  are  limp  and 
powerless,  so  that  the  limb  or  limbs  hang  quite  useless  and  flail-like.  In 
the  more  severe  cases  almost  all  the  muscles  in  the  body  appear  to  be 
involved ;  the  child  cannot  sit  up,  its  head  falls  to  one  side  through  paresis  of 
the  muscles  of  the  neck,  its  cry  is  weak  or  almost  lost  from  weakness  of 
the  diaphragm  and  intercostals,  its  respiration  is  shallow  and  rapid,  and  its 
limbs  relaxed  and  motionless.  The  paralysis  may  be  confined  to  one  limb 
or  a  group  of  muscles  in  a  limb  :  thus  an  arm  may  hang  useless  by  the  side, 
and  if  raised  above  the  head  falls  flail-like  by  the  side.  One  or  both  legs 
may  be  powerless,  and  may  be  flexed,  extended,  or  rotated  without  any 
resistance  from  the  tonus  of  the  muscles.  The  muscles  of  the  neck,  back, 
and  intercostals  may  be  affected.  Hemiplegia  is  rare.  The  reflexes,  both 
superficial  and  deep,  are  lost,  so  that  tickling  the  sole  of  the  foot  or  per- 
cussing the  patellar  tendon  meets  with  no  response.  It  is  difficult  to  judge 
if  there  is  any  loss  of  sensation  or  at  least  sensory  paralysis.  In  the  most 
severe  cases  we  have  noticed  that  sensation  is  not  as  acute  as  usual :  a  spoon, 
which  to  a  normal  skin  is  unbearably  hot,  can  be  borne  without  eliciting 
any  expression  of  pain  on  a  recently  paralysed  foot,  and  in  the  same  way  a 
pamfully  severe  application  of  faradaism  will  be  borne  without  flinching.. 


Acute  Atrophic  Paralysis  581 

It  must  be  borne  in  mind,  however,  that  the  circulation  in  the  skin  is 
interfered  with  by  the  lesion  of  the  cord,  and,  moreover,  it  is  much  more 
difficult  to  test  the  sensations  of  an  infant  six  or  eight  months  old  than  it  is 
those  of  an  adult.  The  functions  of  the  sphincters  of  the  bladder  and  rectum 
are  rarely  interfered  with.  We  have,  however,  seen  one  case  of  a  boy  aged 
four  years  where  for  a  few  days  after  the  onset  of  the  paralysis,  which  afifected 
both  legs,  a  catheter  had  to  be  used  twice  a  day  on  account  of  paralysis  of 
the  bladder. 

The  irritability  of  the  muscles  to  the  faradic  current  becomes  lessened 
during  the  course  of  the  first  week  or  ten  days,  and  is  usually  entirely  lost  in 
those  muscles  where  a  permanent  paralysis  has  taken  place,  and  thus  the 
careful  testing  of  the  muscles  may  be  of  importance  for  prognosis.  To  the 
continuous  current  the  muscle  irritability  is  increasing  during  this  period, 
though  it  gradually  is  lessened  as  the  muscles  waste,  and  may  disappear 
during  the  atrophic  period.  The  quality  of  the  muscle  irritability  differs 
from  normal,  presenting  the  '  reaction  of  degeneration '  ^  due  to  the  degenera- 
tion of  the  nerves  to  the  affected  muscles. 

In  the  majority  of  cases  one  limb  only  is  affected,  and  one  group  or 
groups  of  muscles  more  affected  than  others  ;  in  some  few  cases  the  paresis 
at  first  involves  not  only  the  limbs,  but  the  diaphragm  and  intercostals.  The 
most  severe  case  coming  under  our  notice  was  the  following  : 

A  girl  of  nine  months  was  quite  well  and  health)'  till  June  21  ;  she  was  able  to  raise 
herself  up  in  her  cradle,  and  could  support  herself  with  help  on  her  feet.  She  was  suddenly 
seized  with  convulsions  in  which  her  face  and  arms  twitched  ;  this  was  followed  by  a  dis- 
charge from  one  ear,  and  at  the  same  time  she  was  completely  prostra'ted,  her  voice  was 
hardly  audible,  she  lay  in  bed  perfectly  motionless,  except  a  rolling  of  the  head  from  side 
to  side.  She  was  admitted  to  hospital  on  July  30,  when  the  following  notes  were  made  by 
Dr.  Kershaw  :  '  She  is  a  well-nourished  child  ;  lies  in  bed  quite  helpless  ;  the  lower  ex- 
tremities are  completely  paralysed  ;  there  appears  to  be  some  loss  of  sensation,  as  only  the 
application  of  the  strongest  faradic  current  appears  to  cause  pain.  She  can  bear  without 
crying  the  contact  of  a  hot  spoon,  too  hot  to  be  held  in  one's  own  hand  ;  can  move  right 
arm  at  the  shoulder  and  elbow,  but  not  the  hand  ;  the  left  arm  is  completely  paralysed 
though  she  seems  to  be  able  to  move  the  fingers  slightly.  There  is  paresis  of  the  inter- 
costals, respiration  mainly  abdominal.  No  reactions  to  the  strongest  faradic  current  were 
obtained  in  the  legs,  some  response  could  be  obtained  in  the  flexors  of  the  forearm.  She 
died  of  pneumonia  on  August  7,  forty-seven  days  after  seizure  '  (see  p.  584). 

3.  The  sfage  of  "^  regression''  or  improvement  now  commences,  the  im- 
provement continuing  for  several  months,  many  muscles  being  completely 
restored,  while  others  become  more  and  more  flabby  and  atrophic.  In  rare 
instances  all  the  paralytic  muscles  may  recover.  The  child's  health  at  this 
time  is  usually  good,  it  is  as  bright  and  cheerful  as  usual,  and  there  is  apparently 
nothing  amiss  with  it  except  its  paralysis.     The  muscles,  which  are  gaining 

1  In  a  normal  condition  the  weakest  galvanic  current  which  causes  contraction  of  a 
muscle  is  a  descending  one — i.e.  when  the  anode  or  positive  pole  is  on  the  spine,  while  the 
kathode  or  negative  pole  is  on  the  muscle,  the  contraction  occurring  on  closure  of  the 
current.  This  is  the  kathode  closure  contraction,  K.C.C.  WTien  there  has  been  degene- 
ration of  nerves,  contraction  may  occur  more  readily  with  an  ascending  current — that  is, 
with  the  anode  on  the  muscle  :  the  anode  closure  contraction,  A.C.C.  Normally,  K.C.C. 
is  greater  than  A.C.C. ;  in  nerve  degeneration  A.C.C.  may  be  equal  to  or  greater  than 
K.C.C.  Normally,  the  opening  anodal  current,  A.O.C. ,  is  greater  than  the  kathodal 
opening  current,  but  this  may  be  reversed  in  disease. 


582  Diseases  of  the  Xervons  System 

in  power,  respond  more  readily  to  the  interrupted  current  than  at  first,  %\-hile 
the  atrophic  muscles  fail  entirely  to  react. 

4.  After  some  months  improvement  ceases,  or,  at  least,  any  improvement 
which  takes  place  six  months  after  the  onset  is  usually  very  slight  indeed. 
The  atrophy  mostly  goes  on,  and  certain  contractures,  especially  affecting 
the  leg  below  the  knee,  leading  to  deformities,  are  apt  to  take  place.  At  this 
period  it  is  possible  to  make  a  forecast  of  the  amount  of  paralysis  which  is 
likely  to  be  permanent,  and  take  stock,  as  it  were,  of  the  real  damage  which 

has  taken  place,  which  is  pro- 
r  ~~    ~~~       "  '■     ~  ^       bably  much  less  than  at  first 

appeared  likely.  This  per- 
manent paralysis  may  affect 
a  whole  limb,  though  it  rarely 
does  this,  some  groups  being 
entirely  powerless,  others 
only  slightly  weakened  or  not 
affected  at  all. 

Sometimes  the  groups  af- 
fected are  associated  together 
in  their  actions,  as  when  the 
upper  arm  type  of  Erb  is 
present,  the  deltoid,  spinati, 
biceps,  and  supinators  being 
affected,  while  the  muscles 
of  the  forearm,  excepting  the 
supinators,  escape,  the  lesion 
in  the  cord  being  situated  on 
a  level  with  the  fifth  and  sixth 
cervical  roots  (see  fig.  129). 
It  is  important  to  remember 
that  the  groups  have  no  rela- 
tion to  their  peripheral  nerve 
supply,  such  as  would  be 
present  if  the  paralysis  was 
extra-spinal.  Very  often  the 
muscles  paralysed  haA-e  no 
relation  to  one  another,  being 
picked  out,  as  it  were,  at 
random. 

In  the  lower  limb  the 
muscles  below  the  knee  usu- 
ally suffer  more  complete  paralysis  than  those  of  the  thigh  or  buttock.  The 
peronei  usually  suffer  most,  the  result  being  that  the  heel  is  drawn  up  and  the 
foot  turned  inwards  (talipes  equino-varus)  by  the  unbalanced  action  of  the 
gastrocnemius  ;  as  time  goes  on  the  contracted  condition  of  the  calf  muscles, 
aided  by  the  shortening  of  the  leg,  becomes  permanent  in  consequence  of  a 
fibroid  degeneration  taking  place,  and  the  foot  can  no  longer  be  dorso-flexed. 
In  the  same  way  talipes  valgus  may  be  produced  by  paralysis  of  the  tibialis 
anticus,  more  rarely  talipes  calcaneus  by  the  paralysis  of  the  gastrocnemius. 


Fis.  128. 


-A.  H.,  aged  9  years.   Acute  Atrophic  Paralj'sis, 
legs,  back,  and  arms  affected. 


Acute  Atrophic  Paralysis 


;83 


Both  legs  below  the  knee  may  be  paralysed,  both  extensors  and  flexors  ;  and 
the  patient  cannot  stand,  but  progresses  by  crawling  on  his  hands  and  knees, 
dragging  his  wasted  legs  after  him. 

Of  the  thigh  muscles,  the  rectus,  vasti,  and  adductors  are  more  often 
paretic  than  the  hamstrings,  and  thus  flexion  of  the  knee  may  result  and 
become  permanent.  The  gluteal  muscles  and  rotators  of  the  hip  are  often 
weak,  so  that  the  child  in  walking  gives  way  at  the  hip. 

In  the  upper  extremity  the  muscles  of  the  shoulder  suffer  most  frequently, 
the  deltoid  being  especially  prone  to  attack  ;  usually  the  supra-  and  infra- 
spinati,  biceps,  triceps,  and  supinators  are  associated  together  :  in  such  cases 
the  shoulder  droops  from  the  weight  of  the  arm,  and  the  head  of  the  humerus 
may  slip  readily  out  of  its  socket.  The  serratus  magnus,  pectoral  muscles, 
and  intercostals  may  also  be 
affected.  The  forearm  muscles,  both 
extensors  and  flexors,  together  or 
singly,  may  be  affected  ;  less  often 
those  of  the  hand.  Contractures 
are  less  often  present  in  the  arms 
than  in  the  legs. 

The  muscles  of  the  spine,  sacro- 
lumbahs,  &c.,  and  those  of  the 
neck  and  diaphragm,  are  rarely 
permanently  paralysed.  Lordosis 
is  present  if  the  sacro-lumbalis  is 
weakened.  Lateral  curvature  may 
be  present.  In  severe  cases  the 
paralysis  is  very  extensive,  render- 
ing the  patient  veiy  helpless.  Thus 
in  the  case  of  the  boy  figured  128 
and  129,  he  could  manage  to  sit  up 
for  a  short  time,  if  helped,  by  sup- 
porting his  trunk  with  his  hands 
and  arms.  'Both  legs  were  almost 
completely  paralysed.  The  inter- 
costals were  partially  paralysed,  and 
so  also  were  the  arms. 

The  paralysed  muscles  are  always  atrophied,  though  at  times  much  sub- 
cutaneous fat  may  give  a  delusive  appearance  of  solidity  to  the  muscle.  In 
the  most  wasted  muscles  there  is  a  complete  loss  of  faradic  irritabilitv" :  there 
is  usually  more  or  less  present  in  those  only  partially  paralysed.  The  irrita- 
bility to  the  continuous  current  gradually  disappears  as  atrophy  progresses, 
and  in  the  wasted  muscles  becomes  completely  lost. 

Arrest  of  dru'elopiiient  of  the  limbs  which  are  paralysed  also  takes  place  ; 
the  bones  appear  to  grow  more  slowly  on  the  paralysed  side.  Other  bones 
such  as  the  ribs  and  pelvis  may  be  affected.  The  joints  often  become  more 
movable  from  relaxation  and  stretching  of  the  ligaments,  as  w-ell  as  from  the 
loss  of  support  attorded  by  the  normal  muscles  ;  the  articular  ends  may 
become  deformed.  The  circulation  through  the  skin  of  the  paralysed  limbs 
becomes  slow,  the  surface  has  a  blue  or  purplish  appearance  and  feels  cold 


Fig.  129. — A.  H.,  aged  o  years.  Acute  Atrophic 
Paralysis  ;  he  can  sit  up  by  help  of  hand  ;  right 
shoulder  muscles  paral\'sed  (upper  arm  t^-pe). 


584  Diseases  of  the  N'ervous  System 

to  the  touch.  Chilblains  and,  ulcers  are  apt  to  form  on  the  paralysed  limbs, 
and  be  slow  to  heal.  The  bones  themselves  frequently  degenerate  ;  in 
some  cases  little  true  bone  may  remain,  fat  taking  the  place  of  the  osseous 
tissue.  Injuries,  operative  or  accidental,  of  such  limbs  are  slow  in  healing  ; 
on  the  other  hand,  acute  inflammations  rarely  attack  the  tissues. 

Pathology. — There  is  an  acute  inflammation,  the  greatest  stress  of  which 
falls  on  the  anterior  cornua  of  the  grey  matter  in  the  cervical  and  lumbar 
enlargements.  In  severe  cases  the  grey  matter  of  the  dorsal  cord  is  also 
affected.  There  is  strong  reason  to  believe  that,  in  some  cases  at  least,  the 
inflammation  is  not  confined  to  the  anterior  cornua,  but  involves  more  or  less 
the  whole  cord  ;  but  the  principal  damage  caused  by  the  effusion  of  blood  and 
inflammatory  products  occurs  in  the  most  vascular  part  of  the  cord,  and  this 
is  in  the  anterior  cornua  where  the  large  nerve  cells  are  situated.  During  the 
acute  stage  of  the  attack,  where  there  is  perhaps  a  high  temperature  and  con- 
vulsions, there  is  probably  an  inflammatory  engorgement  of  the  whole  cord, 
possibly  of  the  whole  of  the  nervous  centres  :  then  an  exudation  of  inflam- 
matory material  takes  place  which  leads  to  both  temporary  and  perma- 
nent damage  to  the  motor  cells  in  the  anterior  cornua  of  the  cervical  or 
lumbar  enlargements.  During  the  next  few  months  an  absorption  of  inflam- 
matory material  and  perhaps  also  repair  of  damage  by  the  formation  of  new 
nerve  fibres  or  cells  goes  on,  while  a  certain  amount  of  muscular  power  which 
has  been  lost  is  regained.  Finally  a  sort  of  cicatrisation  or  shrinking  takes 
place,  leaving  a  permanent  paralysis  of  the  muscles  supplied  by  the  nerve 
centre  which  has  been  destroyed. 

Very  few  observations  have  been  made  on  the  cords  of  those  dying  during 
the  acute  attack  or  at  the  onset  of  the  paralysis.  In  Drummond's  case,^  that 
of  a  child  of  five  years  who  died  in  a  few  hours,  the  vessels  supplying  the 
anterior  horns  were  distended  with  blood,  the  microscope  showing  minute 
extravasations  of  blood  and  changes  in  the  nerve  elements.  A  case  re- 
corded by  Charlewood  Turner,  dying  six  weeks  after  the  attack,  showed 
softening  of  the  anterior  horns,  spots  where  the  grey  matter  had  undergone 
complete  degeneration,  and  an  exudation  of  leucocytes  had  taken  place  from 
the  vessels.  In  our  own  case,  p.  581,  similar  changes  were  visible  in  the  grey 
matter  of  the  lumbar,  cervical,  and  dorsal  portions  of  the  cord,  and  changes 
such  as  effusion  of  leucocytes  from  vessels  were  noted  in  the  white  matter,  as 
well  as  the  grey.  Moreover,  even  in  the  medulla  it  was  evident  that  an 
engorgement  of  the  vessels  had  taken  place. 

Degenerative  changes  take  place  in  the  nerves  which  are  connected  with 
the  damaged  centres  in  the  cord  ;  the  muscles  also  waste  ;  their  connective 
tissue  becomes  hypertrophied,  so  that  in  extreme  cases  very  few  muscular 
fibres  are  left.  The  muscles  which  antagonise  the  paralysed  muscles  mostly 
also  waste,  their  muscular  fibres  becoming  replaced  by  connective  tissue. 

Diagnosis. — The  diagnosis  during  the  acute  attack  is  always  difficult, 
mostly  impossible  ;  the  fever,  delirium,  and  convulsions  sometimes  present 
naturally  suggest  some  cerebral  disease  such  as  meningitis  or  the  onset  of 
scarlet  fever  or  pneumonia.  It  is  only  when  paralytic  symptoms  present 
themselves  that  the  diagnosis  is  made  ;  even  then  the  paralysis  maybe  over- 
looked, especially  in   young   children,  it  being  supposed  that  the  child  is 

1  Brain,  April  188.S. 


Acute  Atrophic  Paralysis  585 

simply  weak  as  the  result  of  the  acute  attack.  When  once  the  paralysis  has 
set  in,  diagnosis  is  easy,  though  when  paraplegia  is  present  the  distinction 
between  transverse  myelitis  of  the  lumbar  region  and  polio-myelitis  may 
not  be  easy.  In  transverse  myelitis  there  will  be  certainly  loss  of  sensation  ; 
this  is  said  not  to  occur  in  cornual  myelitis,  though  in  the  case  recorded 
(p.  581)  there  was  undoubted  slight  loss  of  sensation.  In  transverse  myelitis 
of  the  dorsal  region,  its  commonest  seat,  there  will  be  no  loss  of  faradic 
irritability,  and  after  a  few  days  or  a  week  the  reflexes  will  return  and  become 
excessive,  and  ankle-clonus  can  usually  be  obtained. 

In  cerebral  paralysis  there  is  no  loss  of  faradic  irritability,  and  no  mus- 
cular wasting  takes  place. 

Treatment. — The  treatment  of  anterior  polio-myelitis  in  the  early  stages 
is  that  of  an  acute  inflammatory  lesion  of  the  cord.  The  child  must  be  kept 
as  quiet  as  possible  in  bed,  given  a  milk  diet,  and  good  may  possibly  be  done 
by  applying  mustard  poultices  to  the  spine.  If  there  is  fever,  aconite  and 
bromide  of  potassium  may  be  given.  When  the  acute  stage  has  passed  aw^ay, 
and  the  child  is  left  in  a  prostrate  condition,  the  greatest  care  must  be  taken 
to  keep  the  child  at  rest  as  much  as  possible,  all  excitement  of  every  kind 
being  avoided.  It  must  be  borne  in  mind  that,  in  patients  dying  many 
weeks  or  even  two  or  three  months  after  the  onset,  evidences  of  the  inflam- 
matory lesion  may  still  be  found  in  the  cord,  and  during  this  period  absorp- 
tion of  inflammatory  material  is  going  on,  and  the  object  to  be  aimed  at  in 
treatment  is  to  secure  the  recovery  of  as  much  of  the  damaged  cord  as 
possible.  A  variable  amount  of  nerve  tissue  has  been  certainly  irretrievably 
damaged,  but  some  of  the  damage  done  is  recoverable,  and  the  more  the 
general  health  is  maintained  and  the  child  kept  at  rest,  the  more  is  it  likely 
that  recovery  will  take  place. 

It  may  be  doubted  if  there  are  any  medicines  which  have  any  direct 
influence  over  the  nutrition  of  the  cord  or  directly  influence  any  morbid 
processes  going  on.  Perhaps  the  most  likely  drugs  to  be  of  service  are 
sedatives  such  as  belladonna  and  bromides  in  combination  with  iron  or 
quinine. 

The  c[uestion  of  how  soon  should  massage  or  electrical  treatment  be 
begun  is  an  important  one  ;  for,  on  the  one  hand,  the  paralysed  muscles  are 
quickly  wasting  on  account  of  their  nerve  centres  being  damaged,  but  on 
the  other  hand  the  disturbance  of  the  child,  the  fright  and  excitement  of 
the  daily  application  of  the  battery,  are  not  unhkely  to  do  harm.  The 
application  of  the  battery  current  is  hardly  likely  to  modify  or  favourably 
influence  the  lesion  in  the  cord,  but  it  may  help  to  maintain  the  nutrition  of 
the  muscles  while  recovery  is  taking  place  in  the  cord.  On  the  whole  we 
are  inclined  to  believe  that  gentle  rubbing  or  massage  of  the  paralysed 
limb  or  limbs  may  be  practised  from  the  first,  and  voltaic  currents  may  be 
used  within  a  month  or  six  weeks.  It  is  wise  to  begin  with  a  very  weak  current, 
at  first  using  large  wetting  sponges  as  electrodes,  and  frequently  interrupting 
the  current,  which  after  a  few  applications  should  be  just  strong  enough  to 
secure  a  contraction.  The  application  should  be  made  daily  for  many 
months,  especial  care  being  taken  to  select  the  paralysed  muscles  in  the  limb. 

An  important  part  of  the  treatment  is  to  encourage  the  patient  to  put 
forth  as  much  voluntary  power  as  possible,  and  he  should  constantly  try  to 


586 


Diseases  of  the  Nervous  System 


use  the  weakened  limb.  We  believe  that  systematic  attempts  to  use  the 
paretic  muscles,  combined  with  shampooing  of  the  limb,  are  more  likely  to 
promote  recovery  than  any  electrical  applications.  The  circulation  in  the 
paralysed  limb  is  certain  to  be  slow  and  defective  ;  friction  of  the  skin,  with 
kneading  of  the  muscles,  is  certainly  beneficial  ;  while  a  well-selected  series 
of  movements  attempted  on  the  part  of  the  patient,  or  carried  out  by  an 
attendant,  assists  the  return  of  power  in  the  muscles.  These  measures  must 
in  most  cases  be  pei'severed  in  for  many  months,  if  not  years,  in  the  hope  of 
improvement.  The  paralysed  limbs  must  be  warmly  clad  and  carefully  pro- 
tected from  cold. 

Much  may  be  done  in  the  chronic  stage  by  means  of  mechanical  devices 
such  as  the  application  of  artificial  muscles  and  splints  to  correct  deformities 
and  support  the  limb.     Division  of  the  tendo  Achillis,  plantar  fascia,  and 


Fig.  130. — Peter  L.,  aged  10  years.     Acute  Muscular  Atrophy. 

other  resisting  structures  is  often  required.  For  useless  flail-like  limbs  the 
question  of  excision  of  joints  to  procure  greater  stability,  or  even  of  amputa- 
tion, has  to  be  considered.     (  Vide  also  Chapter  on  Talipes.) 

Chronic  Spinal  IMCuscuIar  Atrophy.    Prog^ressive  Muscular  Atrophy. 

This  disease  for  the  most  part  belongs  to  adult  life,  and  but  rarely  occurs  in 
children  ;  the  progressive  muscular  atrophies  most  common  during  early  life 
are  those  classed  with  the  muscular  dystrophies  (see  p.  588).  The  following 
case  illustrates  this  somewhat  rare  disease. 

Peter  L. ,  aged  10  years.  Mother  stated  that  two  months  ago  she  noticed  he  could  not 
button  his  trousers  or  coat,  about  the  same  time  she  noticed  that  he  walked  badly ;  his 
arms  and  shoulders  have  been  getting  weaker,  and  he  has  difficulty  in  taking  his  coat  off. 
On  admission  it  was  noted  that  the  thenar  and  hypothenar  eminences  of  the  right  hand  were 
extremely  wasted,  indeed  almost  entirely  disappeared  ;  the  interossei  were  much  wasted. 
There  was  similar  wasting  in  the  left  hand,  but  not  so  marked.     The  fingers  of  the  right 


Chronic  Spinal  Muscular  Atrophy  5^7 

hand  wore  extended  at  the  nietacarpo-phalangeal  joints,  thus  giving  the  hand  a  '  claw-like' 
appearance.  There  was  wasting  of  the  right  forearm  and  upper  arm,  both  flexors  and  ex- 
tensors. The  deltoid  was  not  much  affected.  There  was  wasting  of  the  muscles  of  the  sole 
of  the  foot  of  the  right  side,  giving  it  a  hoUowed-out  appearance,  the  right  great  toe  was 
dorso-flexed  at  the  metatarso-phalangeal  joint,  the  calf  and  muscles  of  the  legs  were  flabby, 
but  not  much  wasted.  The  muscles  of  the  left  foot  were  wasted,  but  less  than  the  right.  , 
There  were  no  fibrillar  twitchings  in  the  muscles,  the  knee-jerks  were  increased,  no  ankle- 
clonus,  the  elbow-jerk  was  present.  The  galvanic  reactions  of  both  hypothenar  eminences 
showed  A.C.C.  >  K.C.C.  Interossei  A.C.C  =  K.C.C.  on  the  right  side,  K.C.C.  >  A.C.C. 
on  the  left.  No  contractions  with  a  strong  faradic  current  could  be  got  on  the  right  hypo- 
thenar and  thenar  eminences  ;  a  slight  contraction  on  the  interossei  of  right  and  muscles 
of  the  left  hand.  The  muscles  of  the  scapulae  and  back  are  flabby,  but  there  is  no  definite 
wasting  or  paresis.  The  face  wore  a  more  or  less  expressionless  appearance,  but  there 
was  no  paresis  or  actual  muscular  wasting. 

Neurologists  usually  distinguish  between  the  '  hand-shoulder '  type  and  the 
foot  or  '  peroneal '  type  of  chronic  spinal  muscular  atrophy.  The  first  of 
these  types  is  for  the  most  part  a  disease  of  adult  life,  while  the  peroneal  type 
of  Tooth  mostly  commences  before  puberty.  In  the  case  related  the  wasting 
and  weakness  of  the  hand  and  feet  commenced  about  the  same  time.  Both 
types  have  inany  symptoms  in  common  ;  there  is  gradual  weakness,  and 
marked  wasting  of  certain  groups  of  muscles,  other  groups  of  nmscles 
becoming  gradually  affected.  Usually,  but  not  always,  there  are  idiopathic 
fibrillations  of  the  affected  muscles,  the  faradic  irritability  disappears,  the 
galvanic  irritability  is  lessened  and  altered  in  quality  (reaction  of  degenera- 
tion). In  the  hand-shoulder  type  usually  the  wasting  commences  in  the 
thenar  and  hypothenar  eminences  of  one  hand,  gradually  involving  the  arm 
and  shoulder  and  also  the  muscles  of  the  hand  of  the  opposite  side.  In  the 
peroneal  type,  the  wasting  usually  begins  in  the  extensor  of  the  great  toe, 
the  extensor  of  the  toes,  the  peronei  or  small  muscles  of  the  soles  of  the  feet. 
Gradually,  '  club  foot,'  talipes  equino-varus,  makes  its  appearance.  The 
paresis  and  wasting  may  slowly  spread  to  other  muscles.  We  have  known  a 
slight  degree  of  the  peroneal  type  present  in  several  members  of  the  same 
family — namely,  a  hollowing  out  of  the  sole  of  the  foot,  a  paresis  of  the  peronei 
with  a  resulting  over-action  of  the  gastrocnemius,  and  a  marked  dorsi- 
flexion  of  the  great  toe  (see  fig.  130).  The  '  family  toe '  is  spoken  of  as  a  joke  ! 
This  condition  is  by  no  means  uncommon,  and  may  remain  stationary  for 
years  at  least. 

Peripheral   ITeuritis 

We  have  already  referred  to  the  fact  that  a  form  of  paresis  or  paralysis 
may  accompany  or  follow  an  attack  of  diphtheria.  The  ptomaines  present 
in  the  blood  give  rise  to  a  degeneration  or  neuritis  of  the  terminal  nerve 
fibres.  While  it  is  far  more  common  after  diphtheria  than  any  other  disease, 
it  occurs  also  after  influenza  and  some  other  zymotic  diseases.  Occasionally 
peripheral  neuritis  accompanies  rheumatism  and  chorea,  and  we  have  also 
noted  it  when  no  history  could  be  obtained  of  any  disease  preceding  the 
paralysis.  That  it  occurs  in  connection  with  influenza  we  feel  sure  ;  in  one 
case  coming  under  our  notice  paresis  of  the  ciharis  muscles  occurred  in 
a  boy  aged  seven  years  during  convalescence  from  influenza,  and  where 
diphtheria  could  be    excluded   with    certainty.       In   another   case    of  ours 


588  Diseases  of  the  Nei'vous  System 

of  pneumonia  which  appeared  to  be  due  to  influenza,  paresis  of  the  inter- 
costals,  diaphragm,  and  extremities  supervened  during  convalescence,  and 
ended  fatally. 

The  Muscular  Dystrophies 

In  this  group  the  lesion  is  regarded  as  primarily  muscular,  there  is  a 
tendency  to  occur  in  the  same  family,  and  they  are  specially  characterised  by 
wasting  of  the  muscular  tissues.  The  pseudo-hypertrophic  form  is  by  far 
the  most  common. 

I.  Pseudo-hypertrophic  Paralysis. — Very  little  is  known  about  the 
etiology  of  this  particular  disease.  It  is  apt  to  run  in  families,  and,  strange 
to  say,  while  it  affects  boys  far  more  frequently  than  girls,  in  some 
families  it  affects  the  boys  only,  and  in  others  it  affects  the  girls.  In 
some  cases  there  is  a  family  history  of  the  disease,  and  it  appears  it  may 
be  transmitted  through  the  female  side  without  the  women  themselves 
being  affected  (Gowers).  In  one  of  our  own  cases  the  patient's  brother 
was  an  epileptic,  but  it  rarely  happens  that  any  family  tendency  to  nervous 
disease  exists. 

Symptoms. — In  the  majority  of  cases  symptoms  first  make  their  appearance 
during  the  second  or  third  year,  the  child  being  late  in  learning  to  walk,  the 
parents  attributing  this  to  backwardness  or  weakness.  In  some  cases  the 
symptoms  of  weakness  are  noted  after  the  child  has  been  walking  some  time, 
perhaps  as  late  as  the  six  or  seventh  year.  The  early  symptoms  are  those  of 
weakness  in  the  legs.  As  Gowers  well  put  it,  '  these  children  usually  walk 
late,  also  walk  clumsily,  fall  with  ease,  and  rise  with  difficulty.'  If  placed 
upon  the  ground  they  either  cannot  get  up  without  help,  or,  what  is  more 
likely  in  the  early  stages,  they  are  obliged  to  use  their  hands  in  rising, 
pushing  themselves  off  the  ground  and  catching  hold  of  chairs  or  table- 
legs  to  help  themselves  up.  They  walk  clumsily,  with  a  swaying  gait,  are 
quickly  tired,  and  have  to  be  wheeled  about  in  a  perambulator  long  after 
children  of  a  corresponding  age  are  running  about  and  going  walks. 

In  other  cases  the  friends  pay  little  heed  to  the  backwardness  in  walk- 
ing, but  are  struck  with  the  size  of  the  calves  or  perhaps  apparent  stoutness 
of  the  child.  At  four  or  five  years  of  age,  often  earlier,  the  muscular  hyper- 
trophy is  conspicuous.  The  muscles  of  the  calf  are  strikingly  enlarged,  firm 
and  hard  ;  as  are  usually  also  the  glutei  and  lumbar  muscles — less  often 
the  hamstrings,  extensors  of  the  knee,  and  dorso-flexors  of  the  foot.  Of 
the  other  muscles,  the  infra-spinatus  is,  next  to  the  calf,  the  most  frequently 
enlarged,  and,  as  Gowers  points  out,  this  enlargement  of  the  infra-spinatus 
may  be  of  diagnostic  importance.  The  deltoid  and  supra-spinatus  are  often 
enlarged,  the  latissimus  is  mostly  wasted,  and  the  rule  is  that  the  other 
muscles  of  the  upper  extremity  are  wasted  rather  than  hypertrophied.  In 
rare  cases  the  masseters  and  muscles  of  the  tongue  are  enlarged. 

The  muscles,  whether  enlarged  or  wasted,  are  weak,  and  it  is  this 
vJeakness  of  certain  muscles  which  gives  rise  to  the  characteristic  move- 
ments of  the  child.  The  waddling  gait  is  the  result  of  weakness  of  the 
gluteus  medius  and  extensors  of  the  hip  generally.  The  difficulty  in  rising 
from  the  floor  is  due  to  the  paresis  of  the  extensors  of  the  knees  in  the 
first  part  of  the  act,  and  the  extensors  of  the  hips  in  the  second,  the  patient 


Pseudo-hypertropJiic  Paralysis 


589 


assisting  the  extension  of  the  hips  by  placing  his  hands  on  his  knees,  and 
'  climbing  up  himself  by  grasping  his  thighs  alternately  with  his  hands.  ' 

Later  in  the  disease  the  enlarged  muscles 
contract,  the  earliest  to  shorten  being  the  calf 
muscles,  so  that  a  talipes  equinus  is  produced. 
Later  on,  the  knee  and  elbow  may  become 
flexed. 

The  weakness  of  the  extensors  of  the  hip 
produces   a    certain    amount    of    lordosis   or 


Fig.  132.  — Same  case  a.^;  fig.  131  ;  showing  Hj'per- 
trophied  Deltoid  and  Infra-spinati. 


cur\'ature  of  the  spine  Avith  the  concavity 
backwards,  the  patient  assuming  this  position 
in  order  to  maintain  his  balance.     (See  figs. 

131,  132.) 

In    the   last    stages   the  patient  becomes 

entirely  bedridden  and  helpless,  partly  on 
account  of  the  paresis  of  the  muscles,  partly  also  in  consequence  of 
the  muscular  contractions  producing  tahpes  equinus.  In  this  stage  the 
enlarged  muscles  mostly  waste,  and  consequently  lessen  in  size.  The  electric 
irritability  of  the  muscles  is  unaffected  both  to  the  continuous  and  interrupted 
current  at  first ;  later,  as  the  muscular  fibre  wastes,  it  gradually  disappears. 


Fig.  131. — A  case  of  Pseudo-hyper- 
trophic  Paralysis  in  a  boy  of  ten 
years;  showing  enlarged  calves  and 
slight  talipes  equinus. 


590  Diseases  of  the  Nervous  System    ■ 

The  knee  reflex,  at  first  normal,  gradually  disappears  for  a  similar  reason. 
In  children  suffeiing  from  this  disease  the  mind  is  often  weak. 

The  progress  of  the  disease  is  slow,  extending  over  many  years,  the 
patient  possibly  being  helpless  and  bedridden,  having  almost  lost  the  use 
of  his  legs.  He  is  even  unable  to  sit  up  on  account  of  the  wasting  of  the 
spinal  muscles,  but  is  usually  able  to  use  his  hands  to  the  last.  Death  is 
apt  to  take  place  from  bronchitis  ;  this  was  the  case  in  one  of  our  own 
cases  who  lived  to  the  age  of  twelve  years,  the  disease  having  existed  at 
least  eight  years.  In  the  majority  of  cases  where  the  disease  begins  early, 
death  takes  place  soon  after  puberty,  at  any  rate  among  the  hospital  patient 
class  ;  under  the  most  favourable  circumstances,  where  great  care  is  taken 
of  the  patient,  life  may  be  prolonged  to  a  greater  age.  The  course  of  the 
disease  appears  to  be  slower  in  girls  than  boys. 

Diagnosis. — This  is  most  difficult  in  young  children  in  the  early  stages, 
and  in  the  absence  of  typical  enlargement  of  the  calf  muscles  and  infra- 
spinati.  A  fat,  yet  weakly,  child  of  three  or  four  years  of  age,  who  is  late  in 
walking  and  more  or  less  rickety,  may  somewhat  simulate  a  case  of  pseudo- 
hypertrophic paralysis  in  its  gait,  and  in  thedifficulty  of  getting  up.  Usually 
there  is  sufficient  enlargeinent  and  hardness  about  the  gastrocnemii  to  make' 
the  diagnosis  tolerably  clear,  especially  if  there  is  corresponding  enlarge- 
ment of  the  infra-spinatus  and  wasting  of  the  latissimus  dorsi.  In  the 
absence  of  muscular  enlargement,  especially  if  there  is  wasting,  the  disease 
maybe  confounded  with  idiopathic  muscular  atrophy  ;  but  the  latter  disease 
is  rare  before  puberty,  is  apt  to  affect  the  face  and  hands,  and  to  avoid  the 
calf  muscles.  A  fragment  of  muscle  may  be  obtained,  and  muscular  atrophy 
can  be  excluded  if  there  is  an  excess  of  fibroid  and  fatty  tissue  present. 

Prognosis. — The  cases  slowly,  but  surely,  get  worse  ;  the  weakness  year 
by  year  increases,  though  a  certain  amount  of  temporary  improvement  may 
take  place.  We  have  seen  cases  which  we  believe  to  have  been  examples  of 
this  disease  in  a  mild  form  get  entirely  well. 

Pathology. — The  disease  has  been  conclusively  proved  by  the  careful 
examinations  of  Gowers  and  others  to  be  primarily  a  disease  of  the  muscles, 
and  if  changes  take  place  in  the  spinal  cord  they  are  only  secondary.  There 
is  an  overgrowth  of  connective  and  fatty  tissue  ;  it  is  the  latter  which  forms 
the  enlargement  of  the  muscles,  and  it  is  the  absence  of  muscular  fibres 
which  renders  them  weak.  The  shortening  which  takes  place  is  due  to  the 
contraction  of  the  fibrous  tissue. 

Treatment. — Medicines,  except  those  which  are  likely  to  improve  the 
general  health,  are  of  little  use.  The  treatment  which  has  proved  itself  of 
the  greatest  use  in  checking  the  progress  of  the  muscular  wasting  is  exercise 
of  the  affected  muscles  by  well-arranged  movements,  which  the  patient  is 
encouraged  to  perform,  and  friction,  with  passive  movements,  so  as  to  pre- 
vent shortening  of  the  muscles.  We  have  certainly  seen  cases  which  have 
been  admitted  into  hospital  improve  in  no  inconsiderable  degree  under  this 
treatment.  It  is  needless  to  say  it  must  be  systematic  and  carried  out  with 
the  greatest  patience,  if  it  is  to  be  successful. 

2.  Juvenile  rorm  of  I^luscle  Atrophy  (Erb). — This  form  of  muscle 
atrophy  resembles  in  some  respects  pseudo-hypertrophy  of  muscles,  and  some 
cases  occur  in  which  it  may  be  difficult  to  say  to  which  class  they  belong. 


Muscle  Ati'ophy  591 

We  note  here  also  the  tendency  to  run  in  families,  as  in  pseudo-hypertrophic 
paralysis.  There  is  weakness  and  wasting  of  certain  groups  of  muscles. 
The  upper-arm  muscles  are  usually  first  affected— namely,  the  biceps,  triceps, 
and  supinator  longus  ;  the  lower  part  of  the  pectoralis  major  and  minor,  and 
also  the  serratus,  trapezius,  latissimus  and  rhomboidei  often  also  suffer  more 
or  less  atrophy.  The  deltoids,  infra-  and  supra-spinatus,  usually  escape  ;  in 
some  cases  they  ha\e  been  described  as  hypertrophic.  The  muscles  of  the 
forearm  and  hand  usually  escape.  In  the  legs,  the  cjuadriceps,  the  flexors 
of  the  hip,  and  glutei,  the  peronei  and  tibialis  anticus  may  be  affected.  The 
muscles  of  the  spine,  especially  the  sacro-lumbalis,  may  be  wasted  more  or 
less.  The  electric  irritability  of  the  muscles  is  lessened  in  proportion  to  the 
wasting.  There  is  no  reaction  of  degeneration.  The  disease  is  essentially 
chronic. 

3.  Infantile  IVIuscle  Atrophy  of  the  Face  (Landouzy,  Dejerine). — This 
form  is  closely  related  to  (2),  if  not  actually  belonging  to  the  same  class. 
This  disease  appears  to  be  almost  entirely  observed  in  children.  There  is 
wasting  of  the  muscles  of  the  face,  especially  the  orbicularis  oris,  zygomatics, 
and  frontalis.  The  expression  of  face  is  peculiar,  and  there  is  a  curious 
alteration  of  expression  if  the  child  laughs  or  smiles,  on  account  of  the 
paralysis  of  the  zygomatics  which  elevate  the  angles  of  the  mouth.  On  account 
of  the  weakness  of  the  orbicularis  oris,  the  lips  are  separated  and  the  lower  lip 
protrudes.  The  tongue,  eyeball  muscles,  and  muscles  of  mastication  escape. 
The  course,  like  that  of  other  diseases  of  this  group,  is  chronic  and  pro- 
gressive. 

IMCyotonie.     Thomsen's  Disease 

The  first  symptoms  of  this  rare  disease  are  first  observed  during  child- 
hood, and  apparently  persist  through  life.  The  disease  is  apt  to  affect 
several  members  of  the  same  family,  and  can  be  traced  back  through  several 
generations.  The  characteristic  symptom  is  that  whenever  the  patient 
attempts  to  move,  the  muscles  assume  a  condition  of  cramp  or  tonic  spasm. 

After  a  few  attempts  to  use  his  limbs  the  patient  succeeds  in  gaining 
command'of  the  muscles,  and  the  spasm  does  not  return  till  after  a  period  of 
rest.     No  treatment  appears  to  be  of  any  use. 

Our  colleague  Mr.  Whitehead  recently  (1898)  showed  us  a  little  girl  with 
a  condition  of  the  skin  of  the  thigh  and  of  the  underlying  adducta  longus 
apparently  exactly  like  that  seen  in  cases  of  Dupuytren's  contraction  in  the 
hand.  It  has  been  slowly  coming  on,  and  no  cause  for  its  onset  was  known. 
The  femoral  lymphatic  glands  were  enlarged,  and  possibly  the  affection  may 
have  been  one  primary  of  the  lymphatics,  but  there  appeared  no  doubt  that 
the  muscles  were  definitely  implicated  in  the  sclerosing  process. 


592  Diseases  of  the  Genito-urinary  System 


CHAPTER   XXVII 

DISEASES   OF   THE   GENITO-URINARY   SYSTEM 

Abnormal   Conditions   of  Urine 

We  have  already  referred  to  the  fact  (page  7)  that  while  infants  and  children 
pass  a  smaller  quantity  of  urine  per  diem  than  adults,  yet  relatively — for  their 
weight — they  pass  more,  and  this  is  also  true  of  the  urea  excreted.  The 
amount  of  urine  passed  is  influenced  by  slighter  causes,  such  as  cold  feet, 
chills,  indigestion,  &c.,  during  early  life  than  later.  Speaking  generally,  the 
urine  excreted  by  children  is  of  a  paler  colour,  lower  specific  gravity,  and  is 
less  concentrated  than  the  urine  of  adults.  The  amount  passed  is  increased 
in  such  conditions  as  diabetes  mellitus  and  insipidus,  while  it  is  diminished 
in  acute  nephritis  and  most  febrile  conditions. 

Iiithaemia.  Vricacidsemia. — We  have  quoted  the  observations  of 
Carriere  and  Monfit  (page  7)  to  the  effect  that  both  actually  and  relatively 
less  uric  acid  is  excreted  by  children  as  compared  with  adults  ;  but  we  must 
add  that  this  is  not  in  accordance  with  the  observations  of  some  other  authors. 
Thus  Haig  says,  '  for  while  in  adults  urea  is  formed  in  about  the  proportion 
of  three  or  four  grains  per  pound  of  body-weight  per  day,  uric  acid  in  its 
normal  relation  to  urea  of  i  to  35  would  be  about  -09  to  "ii  grain  per  pound 
per  day  ;  in  a  child  3  or  4  years  old  urea  may  be  as  much  as  9  or  10  grains 
per  pound  and  uric  acid  "27  to  -3  grain  per  pound  of  body-weight.' . 

Unfortunately  the  estimation  of  uric  acid  in  the  urine  is  a  complicated 
process  and  there  is  no  clinical  method  of  ascertaining  with  certainty  if  the 
uric  acid  in  the  urine  is  above  or  below  the  normal  amount.  Uric  acid  is 
only  in  evidence  when  it  is  deposited  in  fine  reddish  crystals,  or  as  a  bulky 
precipitate  in  the  form  of  urates  which  separates  from  the  urine  on  cooling ; 
the  degree  of  acidity  and  concentration  of  the  urine  must  be  taken  into 
account  in  judging  whether  there  is  an  excessive  quantity  of  uric  acid  being 
excreted  or  not.  We  find  a  more  or  less  copious  deposit  of  uric  acid  is 
common  in  children  convalescent  from  scarlet  fever  and  other  febrile 
diseases,  and  it  is  said  to  occur  also  in  children  who  have  inherited  a  gouty 
diathesis.  This  sandy  deposit  is  seen  not  uncommonly  in  the  urine  of  quite 
young  children,  and  such  may  complain  of  soreness  and  redness  around  the 
meatus  ;  often  as  much  as  a  teaspoonful  of  deposit  may  be  seen  in  the  cham- 
ber vessel  in  the  morning.  In  one  case  we  knew  of,  as  much  as  a  table- 
spoonful  could  be  seen  at  times,  especially  in  urine  passed  with  a  stool,  or 
after  some  rough  movement  as  a  pony  ride.     In  such  cases  presumably  the 


HcBmaturia  593 

uric  acid  has  been  deposited  in  the  kidneys,  pelvis,  or  bladder,  and  becomes 
dislodged  by  straining-  at  stool  or  by  rough  movements. 

Ii  is  very  common  to  find  urates  deposited  from  urine  on  standing  and 
cooling.  There  is  not  much  significance  in  this,  though  if  it  occurs  habitually 
we  should  naturally  be  suspicious  that  an  excess  of  uric  acid  was  being 
excreted.  It  usually  occurs  when  the  skin  has  been  acting  freely  and  the 
urine  is  concentrated. 

Haig  has  collected  evidence  to  show  that  an  excessive  quantity  of  uric 
acid  in  the  blood  or  joints  may  give  rise  to  headache,  asthma,  eczema, 
epilepsy,  Bright's  disease,  rheumatism,  &c.,  but  it  cannot  be  said  that  his 
views  have  been  universally  accepted  in  their  entirety. 

In  those  children  who  pass  from  time  to  time  uric  acid  in  their  urine,  it 
is  well  to  give  alkalies,  as  citrate  of  potash,  efif.  phosphate  of  soda,  or 
Carlsbad  salts.  The  diet  should  consist  for  a  time  at  least  of  vegetables, 
eggs  and  milk  ;  butcher's  meat,  beef  teas,  and  meat  extracts  being  avoided. 

Haematuria. — Blood  is  present  in  the  urine  in  a  variety  of  conditions,  in 
general  diseases  as  well  as  in  local,  and  a  difficulty  may  not  infrequently  be 
experienced  in  determining  the  source  from  which  the  bleeding  takes  place. 

Htematuria  or  ha^moglobinuria  occurs  at  times  in  infants  a  few  days  or 
weeks  old,  who  are  also  jaundiced  ;  epidemics  of  such  cases  have  been 
described  by  Winckel  and  Bigelow  as  occurring  in  lying-in  hospitals  (p.  29). 
Two  fatal  cases,  in  which  h;jemoglobinuria  was  present  in  infants  five  months 
and  eight  months  old  respectively,  have  been  described  by  Hirschsprung. 
In  both  cases  the  symptoms  supervened  suddenly  ;  there  was  cyanosis,  dark 
albuminous  urine  and  feverishness  ;  in  one  of  the  cases  there  was  dyspnoea 
(urcemic)  and  tetany  of  the  hands  and  feet.  The  post-7nortem  showed  that 
all  the  organs  were  of  a  dirty  brown  colour,  and  the  blood  in  the  body  had 
undergone  a  remarkable  change.  Similar  cases  have  occurred  from  poison- 
ous doses  of  chlorate  of  potash,  but  neither  of  these  cases  had  been  taking 
this  salt. 

Haematuria  occurs  in  rare  cases  in  wasted  infants  and  young  children 
from  thrombosis  of  one  of  the  renal  veins,  a  consequent  hccmorrhagic  infil- 
tration of  the  kidney  taking  place. 

We  should  say  the  commonest  cause  of  hsematuria  in  infants  and 
children  under  two  years  of  age  is  infantile  scurvy  (p.  194).  In  some  cases 
haematuria  is  the  first  symptom  ;  usually  spongy  gums  are  present,  but 
periosteal  tenderness  may  be  absent.  Hsematuria  may  succeed  the  tenderness 
and  immobility  of  the  hmbs.  The  infant  is  generally  pallid  and  is  more  or 
less  markedly  rickety.  The  nurse  probably  notices  that  the  urine  stains  the 
napkin,  it  may  be  bright  red,  or  in  milder  cases  a  yellowish-red  colour.  If 
the  urine  is  passed  into  a  vessel  a  red  sediment  of  blood  corpuscles  settles 
to  the  bottom,  leaving  the  fluid  portion  tolerably  clear,  but  if  much  blood  is 
present  the  supernatant  liquid  is  bright  red.  We  can  call  to  mind  several 
instances  where  infants  suffering-  from  heematuria  from  this  cause  were 
sounded  for  stone  ;  it  is  needless  to  say  that  no  stone  was  found,  and  they 
quickly  got  well  when  their  diet  was  changed.  It  is  uncertain  whether  the 
blood  oozes  from  the  kidneys  or  bladder.  In  these  cases  there  is  no  nephritis, 
only  a  passive  oozing  of  blood. 

Haematuria  may  be  the  first  symptom  of  hsemophilia,  and  in  any  case 

QQ 


594  Diseases  of  the  Genito-iirinary  System 

where  the  diagnosis  is  doubtful  the  family  history  should  be  inquired  into 
for  similar  cases.  Hcematuria  is  often  associated  with  purpura,  and  may 
occur  in  acute  cases  of  variola,  diphtheria,  or  typhus,  resulting  from  the  rapid 
blood  change  which  takes  place  in  these  diseases. 

Hcematuria  may  be  present  in  acute  nephritis  ;  in  this  case  the  urine  is 
usually  of  a  smoky  tint,  or  more  the  colour  of  porter,  l3ut  in  some  cases  the 
colour  may  be  bright  red  from  the  large  amount  of  blood  which  it  contains. 
We  have  seen  hcemorrhagic  nephritis  following  scarlet  fever,  diphtheria,  and 
pneumonia.  A  microscopical  examination  of  the  deposit  which  falls  to  the 
bottom  of  the  glass  after  the  urine  has  stood  for  a  while  will  show  blood  and 
epithelial  casts  in  cases  of  nephritis.  Blood  in  the  urine  also  occurs  in  cases 
of  renal  or  vesical  calculus,  more  rarely  in  tubercular  kidney,  sarcoma  of  the 
kidney,  and  vascular  growths  in  the  urethra  or  bladder. 

Poisoning  by  chlorate  of  potash,  cantharides,  or  turpentine  as  a  cause  of 
hasmaturia  must  not  be  forgotten. 

Intermittent  Ksemogrloblnuria  occurs  in  children  as  in  adults,  but  it  is 
a  comparatively  rare  disease. 

Treatment. — The  treatment  necessarily  depends  upon  the  cause,  and  the 
history  of  the  case,  and  other  symptoms  apart  from  hcematuria,  must  be  care- 
fully considered.  It  is  important  to  exclude  stone  in  the  bladder  as  the 
cause  of  hasmaturia,  and  in  all  cases  where  the  cause  of  the  blood  in  the 
urine  is  doubtful  it  is  wise  to  explore  the  bladder  with  a  sound.  Hcematuria 
may  be  the  only  symptom  of  the  presence  of  a  stone.  In  haematuria  depend- 
ing upon  an  impoverished  condition  of  blood  the  most  important  part  of  the 
treatment  consists  in  improving  the  condition  of  the  general  health.  Meat 
juice,  orange  or  lemon  juice,  with  dialysed  iron  or  the  perchloride,  may  be 
given.  Styptics  may  also  be  given,  though  we  have  frequently  been  dis- 
appointed with  their  action.  Of  these,  ex.  hamamelis  liq.  (U.S. P.),  in  5-15 
minim  doses,  may  be  given  every  four  hours,  and  continued  for  some  days. 
Gallic  acid  |^-2  grains,  with  aromatic  sulphuric  acid,  is  sometimes  efficacious 
where  hamamelis  fails.  Spirits  of  turpentine  ^-3  minims  in  mucilage,  or 
liquid  extract  of  ergot  2-10  minims  may  be  tried. 

Pyuria. — Pus  present  in  the  urine  may  come  from  any  part  of  the 
urinary  tract  or  from  an  appendicular,  perinephritic,  or  spinal  abscess  opening 
into  the  bladder  or  urinary  tract.  The  most  common  causes  are  pyelitis, 
tubercular  kidney,  calculus,  and  cystitis. 

Cystlnuria. — Occasionally  cystin  may  be  found  in  considerable  quanti- 
ties. The  urine  is  opalescent  when  passed,  and  on  examining  the  deposit 
after  standing  with  a  low  power  crystals  of  cystin  will  be  seen.  In  a  case  of 
ours  in  a  girl  of  9  years  attacks  of  abdominal  pain  and  vomiting  were 
followed  by  the  appearance  of  cystin  in  the  urine. 

Albuminuria  in  Apparently  Healthy  Children. — Albumen  in  more 
or  less  quantity  is  found  in  the  urine  of  a  considerable  number  of  children  and 
young  adults,  who  have  no  definite  symptoms  of  renal  disease  and  who  are 
in  good  health,  or  at  any  rate  are  not  considered  ill  by  their  friends.  The 
frequency  with  which  this  albuminuria  is  found  during  early  life  has  been 
differently  estimated  by  various  observers.  Thus,  Ward  (quoted  by  Dr.  S. 
West)  found  on  examining  the  urine  of  126  children  attending  Dr.  Garrod's 
out-patients  at  Great  Ormond  Street,  that  one-fourth  (24-6  per  cent.)  con- 


Albiimi)mria  in  Apparently  HealtJiy  Children  595 

tained  more  or  less  albumen  ;  but  in  only  7-5  per  cent,  was  the  amount 
appreciable.  The  test  used  was  boiling  and  the  addition  of  acetic  acid. 
Dr.  Clement  Dukes,  as  the  result  of  his  experience,  concludes  that  at  least 
22  per  cent,  of  schoolboys  (10-18  years)  have  albuminuria.  Probably  every 
physician  who  methodically  examines  the  urine  of  his  patients  in  order  to 
feel  that  he  is  not  overlooking  early  kidney  disease  will  have  been  struck  with 
the  frequency  with  which  he  gets  a  cloudiness  on  boiling  which  does  not 
disappear  on  adding  acetic  acid  ;  and  this  in  patients  or  proposers  for 
insurance  who  have  no  symptoms  of  Bright's  disease.  This  is  especially 
true  in  boys  and  girls  of  school  age.  It  is  not  necessary  for  us  here  to 
discuss  the  significance  of  mere  traces  of  albumen,  or  to  decide  the  some- 
what difficult  question  as  to  whether  the  opalescence  is  due  to  serum 
albumen,  nucleo-albumin,  globulin,  or  some  other  proteid,  though  it  is 
doubtless  wise  in  those  cases  in  which  traces  only  are  found  to  examine,  if 
possible,  other  specimens  passed  at  different  times  of  the  day  and  on 
different  dates.  The  cases  which  are  most  perplexing  and  difficult  are  those 
in  which  considerable  quantities  of  albumen  are  found  in  some  specimens 
and  no  albumen  or  only  traces  in  others.  Such  cases  have  been  described 
as  '  cyclic '  or  '  intermittent '  albuminuria.  They  occur  by  no  means  infre- 
quently in  boys  and  girls  from  8-16  years,  and  are  quite  as  common  in  our 
experience  in  girls  as  in  boys.  The  urine  passed  on  or  before  rising  in  the 
morning  is  free  from  albumen  or  nearly  so,  while  specimens  passed  after 
breakfast  or  midday  give  perhaps  a  thick  cloud  on  boiling,  or  it  may  be 
sufficient  to  deposit  on  standing  5:  to  ^  of  its  volume  of  precipitated  albumen. 
The  amount  varies  during  the  day,  and  is  again  absent  after  a  night's  rest. 
The  urine  is  usually  of  high  specific  gravity,  1025  to  1030,  both  when 
albuminous  and  also  when  free  from  albumen.  No  blood  or  casts  are 
detected  on  microscopical  examination.  There  is  no  puffiness  nor  oedema, 
and  no  cardiac  hypertrophy.  The  patient  appears  quite  well,  and  wonders 
why  he  is  physicked,  dieted,  or  put  to  bed.  The  albumen  disappears  when 
the  patient  is  kept  in  bed  on  a  fluid  diet,  but  probably  appears  again  when 
he  gets  up  and  about  and  goes  back  on  ordinary  diet.  Dr.  C.  Dukes  has 
described  a  similar  class  of  case,  but  calling  special  attention  to  the  fact  that 
the  intermittent  albuminuria  is  very  frequently  associated  with  frontal 
headache,  high  tension  pulse,  and  a  tendency  to  faint.  We  can  certainly 
confirm  his  observations  from  our  experience. 

In  connexion  with  these  cases  we  must  bear  in  rriind  that  intermittent 
albuminuria  is  common  in  children  recovering  from  scarlatinal  nephritis  and 
also  diphtheria.  We  have  often  noticed  in  our  fever  ward  that  in  children 
who  have  had  oedema  and  albuminous  urine  and  apparently  recovered,  the 
albumin  has  disappeared  while  they  were  kept  in  bed  on  a  milk  diet,  but 
reappeared  when  they  were  allowed  to  get  up  and  go  about  the  ward.  We 
have  several  times  discovered  'intermittent'  albuminuria  in  children  in  families 
where  one  or  more  members  have  died  young  of  Bright's  disease.  In  all 
forms  of  Bright's  disease  the  urine  is  apt  to  contain  less  albumen  when  the 
patient  remains  in  bed  than  when  he  is  up. 

What  is  the  prognosis  in  these  cases  of  albuminuria  without  definite 
symptoms  of  ill-health  ?  In  the  majority  of  instances  they  improve,  and 
finally  the  albumen  disappears   in  the   course  of  months   and   years.     In 

Q  Q  2 


596  Diseases  of  the  Genito-urinary  System 

another  class,  the  patient  remains  for  years  zV?  statu  quo  ;  one  of  our  cases 
has  been  more  or  less  under  observation  for  ten  years,  and  is  now  eighteen 
years  of  age,  and  still  has  albumen  in  his  urine.  In  a  third  class,  after 
awhile  definite  symptoms  of  Bright's  disease,  such  as  puffiness  of  the  face 
and  cedema,  develop.    This  has  been  so  in  one  or  two  cases  which  we  know  of. 

The  prognosis  in  any  case  will  be  more  serious  in  those  who  have  at  one 
time  suffered  from  nephritis,  and  in  those  in  which  there  is  a  family  history 
of  Bright's  disease. 

The  treatment  of  these  cases  presents  the  difficulty  that  the  patients  are 
not  ill,  that  the  course  is  chronic,  and  the  friends  are  apt  to  think  that  an 
unnecessary  fuss  is  being  made.  It  is  clear  in  such  cases,  however,  that  a 
guarded  prognosis  must  be  given,  and  every  care  taken,  especially  during 
the  winter  months,  to  guard  against  exposure  to  cold.  Where  there  is 
evidence  of  the  uric  acid  diathesis,  alkalies,  such  as  the  effervescing  citrate 
of  potash,  or  phosphate  of  soda,  should  be  given  with  an  occasional  dose  of 
calomel.  If  there  is  any  history  of  Bright's  disease  in  the  family,  it  is  well, 
if  possible,  for  the  patient  to  winter  abroad  or  in  the  south-west  of  England. 
Butcher's  meat,  in  all  its  forms,  should  be  interdicted,  for  a  while  at  least. 


Diseases  of  the  Kidney 

Cong'enital  Anomalies  of  the  Kidneys. — The  principal  malformations 
of  the  kidneys  found  post  mortem  are  :  (i)  absence,  or  onlj^  a  trace,  of  one 
kidne)',  with  hypertrophy  of  the  other  ;  (2)  'horse-shoe  'kidney,  in  which  the 
two  kidneys  are  united  by  a  bridge  of  kidney  tissue,  giving  the  organs  a  horse- 
shoe shape.  The  kidney  is  placed  with-  its  convexity  downwards,  the  ureters 
passing  down  behind  the  bridge.  (3)  The  kidneys  are  frequently  found 
tabulated^  the  surface  being  deeply  fissured,  or  divided  into  'lobules,'  as  in 
the  foetal  state.     (4)  Movable  kidney. 

These  abnormalities,  though  of  extreme  importance  in  reference  to  opera- 
tions on  the  kidneys  and  the  diagnosis  of  abdominal  tumours,  need  not  be 
further  referred  to  here.  Obliteration  of  one  ureter,  partial  or  complete,  may 
give  rise  to  hydronephrosis  and  recjuire  operation,  as  in  a  case  reported  by 
Tuckwelland  Symonds  of  Oxford.^  Incontinence  of  urine  from  an  abnormal 
opening  of  the  ureter  just  in  front  of  the  meatus  urinarius  has  also  been 
met  with.- 

Displaced  or  movable  Kidney. — '  Floating  kidneys '  are  by  no  means 
rare  in  adults,  especially  in  women  ;  they  are  not  often  discovered  in  infants 
and  children.  We  have  known  several  instances,  but  have  not  seen  a  well- 
marked  cdiSe. post  mortem.  Comby  reports  eighteen  cases  coming  under  his 
notice  ;  sixteen  were  in  girls  and  two  in  boys.  It  is  probable  that  this  condi- 
tion is  usually  congenital,  the  attachment  of  the  kidney  is  longer  and  looser 
than  usual,  and  it  is  surrounded  by  peritoneum  and  attached  by  a  mesentery. 

The  right  kidney  is  affected  in  the  vast  majority  of  cases.  In  fourteen 
of  Comby' s  cases  the  movable  kidney  was  associated  with  dyspepsia  and 
dilatation  of  the  stomach  ;  this  association  of  movable  kidney  and  dyspepsia 

1  Brit.  Med.  Joiir.  November  17,  1883. 

2  Archives  for  Pediatrics,  November  1894. 


Displaced  or  Movable  Kidney  597 

is  common  ;it  all  ages,  and  probably  depends  upon  the  close  connection 
between  the  renal  and  solar  plexuses.  The  same  author  speaks  of 
paroxysmal  pains  in  some  cases,  apparently  from  the  kidney  becoming 
twisted  and  the  ureter  occluded.  In  the  majority  of  cases  no  symptoms  are 
apparently  produced  and  the  movable  kidney  is  discovered  by  accident.  In 
palpating-  the  kidney,  the  left  hand  should  be  placed  in  the  lumbar  region 
laehind,  while  the  right  is  pressed  backwards  from  the  front,  an  attempt 
being  made  to  seize  the  kidney  between  the  two  hands  ;  its  mobility  can  thus 
be  tested.  In  some  cases  the  kidney  can  be  pushed  upwards  under  the  liver 
or  downwards  to  the  brim  of  the  pelvis.  A  severe  case  might  justify 
operation,  otherwise  the  treatment  is  palliative. 

Tumours  of  the  Kidneys. — Swellings  occurring  in  the  region  of  one 
of  the  kidneys  may  be  due  to  one  of  the  following  causes  : 

(i)  New  growth.  (2)  Tubercular  or  other  abscess  in  the  kidney. 
(3)  Hydro-nephrosis.     (4)  Perinephritic  abscess. 

(i)  Renal  PJew  Growths. — In  the  majority  of  cases  a  new  growth  in- 
volving a  kidney  is  a  round-celled  sarcoma  which  begins  outside  the  kidney, 
gradually  displacing  and  compressing  the  kidney  itself.  It  is  difficult  to  say 
exactly  where  these  growths  begin  :  presumably  in  lymphatic  tissue.  In  the 
minority  of  cases  the  new  growth  appears  to  begin  in  the  kidney  itself — at 
least  no  trace  of  the  kidney  can  be  found  ^oj/  morte7n,  but  traces  of  kidney 
structure  may  be  found  scattered  through  the  tumour  on  microscopical 
examination. 

In  some  cases  the  tumour  is  a  myo-sarcoma,  or  in  other  words  it  is  a 
round-celled  sarcoma  with  a  variable  quantity  of  striated  muscular  tissue 
and  spindle-shaped  cells.  In  rare  cases  the  growth  consists  of  alveoli  lined 
with  columnar  epithelium,  similar  in  structure  to  the  cylindrical  epithelial 
carcinomas  found  in  the  large  intestine.  It  is  difficult  to  say  where  such 
tumours  begin  when  occurring  primarily  in  the  kidney  :  possibly  in  the 
remains  of  the  Wolffian  body.  Kelynack  thinks  that  carcinomata  '  probably 
never  occur  in  children.' 

Renal  sarcomata  are  usually  soft  in  consistence,  resembling  brain  sub- 
stance, and  frequently  contain  masses  of  blood  clot  and  altered  blood  in 
consequence  of  haemorrhages  which  take  place  into  their  substance.  They 
often  attain  to  great  size,  weighing  many  pounds,  and  by  their  enlargement  dis- 
place the  other  organs  of  the  abdominal  cavity.  The  hver  or  spleen  is  pushed 
upwards,  the  small  intestines  are  pushed  on  one  side  or  backwards  ;  the 
large  intestine,  where  it  crosses  the  tumour,  is  compressed  against  the 
abdominal  wall  (see  fig.  134).  The  tumour  may  set  up  a  certain  amount 
of  chronic  peritonitis  and  contract  adhesions  to  the  intestines  and  other  viscera. 
Renal  sarcomata  occur  most  commonly  in  children  under  six  years  ; 
of  fifty  cases  collected  by  Seibert,  forty  occurred  during  the  first  five  years  of 
life,  twelve  being  in  infants  under  a  year  old.  In  a  case  recorded  by 
A.  Jacobi  a  sarcoma  was  present  in  the  kidney  of  a  fcetus  born  dead,  and 
other  cases  (Sir  William  Roberts  and  Lloyd  Roberts)  have  been  recorded  in 
which  the  tumours  were  present  at  birth. 

F;   T.  PauV  of  Liverpool,  whose  paper  on  this  subject  is  one  of  the  most 

1  Liverpool  Med. -Chir.  Jour.  January  1894. 


598 


Diseases  of  the  Geitito-urinary  System 


important  of  those  recently  published,  says,  '  The  chief  characteristics  of  con- 
genital renal  sarcomata  are  these  : 

•(i)  They  show  themselves  during   the  first  five  years  of  life,  and  are 
probably  invariably  of  congenital  origin. 

'  (2)  They  are  primarily  extra- renal  though  usually  intracapsular.' 
He  points  out  that  they  may  be  bilateral,  that  they  cause  death  by  ex- 
haustion or  pressure  rather  than  by  urinary  lesions,  that  metastatic  growths 

only  occasionally  occur,  but  all  forms 
of  growth  tend  to  recur  after  removal. 
The  tumours  frequently  contain  striped 
muscle,  embryonic  renal  tissue,  and 
various  forms  of  adult  connective 
tissue.  The  complexity  of  the  struc- 
ture of  these  growths  is  to  be  explained 
by  the  inclusion  within  the  capsule 
which  forms  round  the  embryonic 
kidney  of  elements  of  other  neigh- 
bouring tissues.  Mr.  Paul  describes 
growths  of  the  '  simple  connective 
tissue  type,'  of  the  '  complex  connective 
tissue  type,'  and  of  the  '  renal  adenoma 
type.' 

Kelynack  ('  Renal  Growths  ')  says 
over  52  percent,  of  mahgnant  growths 
occurring  at  all  ages  were  met  with 
below  ten  years,  and  that  most  if  not 
all  of  these  were  sarcomatous. 

Symptoms  and  Course.  —  In  the 
majority  of  cases  enlargement  of  the 
abdomen'  due  to  the  new  growth 
encroaching  on  the  other  abdominal 
organs  is  the  first  symptom  to  call  the 
attention  of  the  friends  to  the  case.  In 
the  minority  of  cases  (one-fifth,  Seibert) 
hcematuria  is  the  first  symptom,  occur- 
ring" at  a  variable  period  before  the 
discovery  of  a  tumour.  The  swelling 
is  first  noted  occupying  the  right  or 
left  lumbar  region,  between  the  ribs 
and  the  crest  of  the  ilium  ;  it  has  a 
rounded  outline,  which  can  be  traced 
downwards,  but  not  into  the  pelvis,  and  upwards  behind  the  fiver  or  spleen. 
By  palpation  it  can  be  separated  from  the  liver  or  spleen.  It  moves  less- 
freely  with  respiratory  movements  than  an  hepatic  or  splenic  tumour  does. 
Percussion  shows  that  the  large  bowel  hes  across  superficially  to  it,  but  if  the 
tumour  is  large  the  colon  may  be  compressed  and  no  tympanitic  note  will 
then  be  detected.  The  swelling  has  a  soft  semi-fluctuating  feel,  and  on 
exploration  with  a  subcutaneous  syringe  pure  blood  is  withdrawn.  During 
the  early  stages  the  patient  appears  perfectly  well,  is  well  nourished,  com- 


Fig.  133. — Malignant  Tumour  of  Kidney  in  a 
girl  of  nine  years.     Dr.  Mutton's  case. 


Renal  Nezv  GrozvtJis 


599 


plains  of  no  pain  and  there  is  no  tenderness  on  handling  the  tumour.  Ex- 
ceptionally pain  is  complained  of;  in  some  cases  it  is  acute  and  due  to 
accompanying  peritonitis.  In  Seibert's  collection  of  fifty  cases  htvmaturia 
was  present  in  nineteen  at  some  time  or  other  during  the  course.  Vomiting 
is  an  occasional  symptom.  As  the  tumour  increases  in  size  it  distends  the 
abdominal  walls,  the  skin  becomes  smooth  and  shiny,  and  is  marked  with 
large  dilated  veins.  The  tumour  pushes  up  the  diaphragm,  passes  perhaps 
beyond  the  middle  hne  in  front,  and  extends  backward  to  the  spine  behind, 
sometimes,  as  in  the  case  fig.  133,  forming  an  enormous  abdominal  tumour. 
The  liver  and  spleen  are  frequently  enlarged  ;  the  patient  gradually 
emaciates  and  has  a  cachectic  appearance  ;  perhaps  the  lower  limbs  become 
cedematous  from  pressure  on  the  vena  cava,  and  death  comes  after  many 
weeks  of  lingering  misery.  Constipation  is  often  present  from  prfessure  on 
the  colon. 

Diagnosis. — A  sarcomatous  enlargement  of  the  kidney  may  be  possibly 
mistaken  for  a  hydro-nephrosis,  abscess  of  the  kidney,  perinephritic,  or  spinal 


Fia 


134. — Congenital  Renal  Sarcoma,  from  a  photograph. 
(F.  T.  Paul.) 


or  other  abscess.  It  is  less  likely  to  be  mistaken  for  a  tumour  of  the  liver 
or  spleen.  A  renal  tumour  may  be  distinguished  from  an  hepatic  or  splenic 
tumour  hy  the  fact  that  it  moves  less  with  respiration  and  the  colon  traverses 
its  anterior  surface,  and  moreover  the  edge  of  the  liver  and  spleen  may  usually 
be  felt.  A  congenital  hydro-7iephrosis,  in  which  the  obstruction  in  the  ureter 
is  complete,  may  cause  some  difficulty  in  diagnosis  ;  there  would  be,  how- 
e\-er,  in  a  swelling  of  any  size,  fluctuation  transmitted  from  the  abdomen  to 
the  flank  in  a  hydro-nephrosis,  and  on  exploratory  puncture  the  fluid  with- 
drawn would  make  the  diagnosis  clear.  An  abscess  in,  or  scrofulous  enlarge- 
ment of,  the  kidney  is  rare  without  a  history  of  pain  and  tenderness  in  the 
lumbar  region,  and  without  pus  in  the  urine.  It  is,  however,  possible  that 
these  may  be  absent,  and  then  the  rapid  growth  in  the  case  of  a  sarcomatous 
kidney  would  in  time  decide  the  diagnosis.  But  a  difficulty  could  rarely 
occur. 


6oo  Diseases  of  the  Genito-urmary  System 

Progftosis. — This  is  necessarily  grave  -.  though  such  tumours  are  chronic 
in  their  course  and  the  patient  may  Hve  for  many  months  or  even  a  year  after 
the  discovery  of  the  tumour. 

Treatme^jit. — As  far  as  we  know,  no  drug  influences  the  progress  of  the 
growth.  Removal  of  a  sarcomatous  kidney  is  usually  followed  so  rapidly  by 
recurrence  that  this,  the  only  possible,  treatment  is  hardly  justifiable  unless 
the  tumour  is  recognised  in  an  early  stage,  when  it  is  worth  trying.  Abbe 
has  had  one  or  two  successful  cases. 

Tuberculous  Kidney. — Tuberculosis  of  the  kidney  is  very  commonly 
met  with  in  children  as  part  of  a  general  tuberculosis.  Thus  of  no  fatal 
cases  of  tuberculosis  in  the  Children's  Hospital  in  the  years  1881-1885  in- 
clusive, in  forty-six  there  was  evidence  of  tubercle  in  the  kidneys  in  larger 
or  smaller  amount.  Most  frequently  the  lesions  are  simply  scattered  grey 
tubercles  in  the  substance  or  on  the  cortex  of  the  organ  :  this  was  the  case 
in  thirty-nine  instances. 

Much  more  rarely  large  masses  of  tuberculous  material  are  found,  or 
occasionally  extensive  destruction  of  the  papillce  and  ulceration  of  the  pelvis, 
and  sometimes  of  the  ureter.  Occasionally  calculi  are  found  co-existing  with 
tuberculous  lesions. 

It  is  rare  in  our  experience  to  find  children  suffering  from  tuberculous 
kidney  apart  from  a  general  tuberculosis  ;  less  than  half  a  dozen  such  cases 
were  admitted  to  the  hospital  in  the  five  j^ears  above  mentioned,  and  genito- 
urinary tuberculosis- — i.e.  lesions  affecting  the  kidneys,  bladder,  testes,  pros- 
tate, vesicula;  seminales — is  not  nearly  so  common  as  in  adult  life,  though 
the  bladder  is  not  rarely  involved.  When  the  tuberculous  lesions  of  the 
kidney  are  only  part  of  a  general  tuberculosis,  life  is  usually  destroyed  before 
the  kidney  affection  is  very  far  advanced,  but  where  the  disease  is  limited 
to  the  urinary  tract  the  whole  of  one  kidney  may  be  destroyed  and  converted 
into  a  mere  sac  with  hardly  a  trace  of  secreting  structure  left.  Very  com- 
monly both  kidneys  are  affected  together,  but  in  a  considerable  proportion  of 
cases  one  organ  alone  is  attacked,  and  under  such  circumstances  life  may  be 
prolonged,  or  even  recovery  may  take  place,  the  damaged  kidney  shrinking 
and  ceasing  to  cause  irritation  ;  the  whole  of  the  work  then  devolves  upon 
its  fellow.  All  stages  of  disease,  from  the  presence  of  a  few  tubercles  to  that 
of  cheesy  masses,  and  on  to  complete  disorganisation,  may  be  found.  Peri- 
nephritic  abscesses  develop  in  some  cases. 

Sympioins. — When  the  kidneys  are  the  seat  of  miliary  tuberculosis  there 
are  usually  no  symptoms  whatever  pointing  to  disease  of  those  organs  :  thus 
of  thirty-nine  cases  of  this  form  of  disease,  in  only  one  was  there  even  albu- 
minuria, and  that  to  a  very  slight  degree.  When,  however,  tuberculous 
ulcers  or  abscesses  exist,  pus,  mucus,  and  large  quantities  of  albumen  may 
be  found  ;  but  the  only  instance  in  which  htematuria  existed  in  the  forty-six 
cases  of  tuberculous  kidney  we  have  examined  was  one  in  which  calculi 
co-existed  with  the  tubercle,  and  undoubtedly  the  presence  of  blood  in  the 
urine  points  to  calculi  rather  than  to  renal  tuberculosis. 

Pain  and  tenderness  are  only  prominent  symptoms  when  there  is  extensive 
disease  and  the  pelvis  becomes  distended  with  pus  and  tuberculous  material, 
and  the  same  statement  holds  good  of  enlargement ;  it  is  only  in  the  later 
stages  of  the  disease  that  any  palpable  enlargement  of  the  kidney  takes  place 


Tuberailous  Kidney — IlydronepJirosis  6oi 

Frequent  micturition  is  rather  a  symptom  of  tuberculous  cystitis  than  of 
renal  disease,  and  where  it  exists  with  evidence  of  tuberculosis  of  the  kidney, 
especially  if  there  is  tenderness  of  the  bladder  and  much  pain  on  sounding 
or  passing  a  catheter,  it  is  tolerably  certain  that  the  bladder  is  affected  as 
well  as  the  kidney. 

The  presence  of  tubercle  bacilli  in  the  urine  would,  of  course,  indicate 
urinary  tuberculosis,  though  without  other  e\idence  it  would  not  show 
whether  the  disease  was  renal  or  not  ;  unfortunately  in  most  cases  of  renal 
tuberculosis  the  bacilli  are  not  to  be  found  until  the  disease  is  far  advanced. 

When  one  kidney  alone  is  affected  and  the  ureter  becomes  blocked  with 
caseous  material  or  granulations,  pyo-nephi"Osis  may  develop  and  form  a 
large  abdominal  tumour  in  which  fluctuation  may  be  detected  :  in  such 
cases  more  or  less  fe\er  will  also  be  present  and  the  diagnosis  will  be  easy. 
It  is  in  the  early  stages  that  a  doubt  arises.  If  there  is  a  tubercular 
history  or  evidence  of  tubercle  elsewhere,  if  the  trouble  is  of  only  a  few 
months'  dui-ation  and  there  is  pus,  but  little  or  no  blood  in  the  urine, 
and  if  there  is  a  gradual  failure  of  health,  the  disease  is  probably  renal 
tuberculosis. 

Treatment. — In  cases  of  miliary  tubercle  nothing,  of  course,  can  be  done 
for  the  renal  affection.  Where  pyelitis  exists  medicine  can  do  something  : 
the  urine  should  be  kept  unirritating  by  the  use  of  diluents  and  boric  acid 
(two-  or  three-grain  doses  in  half  an  ounce  of  peppermint  water)  ;  alkalies  such 
as  carbonate  of  potash  or  liquor  potassje,  or  the  citrate  of  potash  with  hyos- 
cyamus,  will  also  be  found  useful.  If  there  is  lumbar  pain  and  tenderness,  with 
palpable  enlargement  of  the  kidney,  and  the  symptoms  do  not  subside  under 
medicinal  treatment,  nephrotomy  by  the  lumbar  incision  should  be  performed 
and  the  kidney  drained.  If  on  exploration  the  kidney  is  found  entirely  dis- 
organised, and  there  is  evidence  from  the  amount  and  quality  of  the  urine  that 
the  other  kidney  is  sound  and  efficient,  a  trial  should  be  given  to  simple  drain- 
age ;  but,  should  the  discharge  not  decrease,  and  should  the  health  be  failing, 
removal  of  the  affected  kidney  is  called  for.  This,  however,  clearly  can  only 
be  justifiable  if  the  other  organ  is  working  well,  and  if  the  bladder  or 
viscera  are  affected  nephrectomy  would  be  probably  useless.  If  removal  of 
the  kidney  is  decided  upon,  it  should  be  done  before  the  health  is  too  much 
broken  down,  and  the  lumbar  operation  should  be  the  one  selected.  We  have 
only  once  met  with  a  case  in  a  d:/«7rfcallingfor  either  nephrotomy  or  nephrec- 
tomy, so  that  we  do  not  think  suitable  cases  can  be  common. 

Hydronepbrosis  is  not  very  rarely  met  with  in  children,  and  may  be 
congenital  or  the  result  of  partial  blocking  of  the  ureter  by  a  calculus  or 
cicatrix.  Complete  obstruction  of  the  ureter  appears  to  lead  usually  to 
atrophy  of  the  kidney  rather  than  to  hydronephrosis. 

The  dilated  kidney  forms  a  tumour  which  has  characters  like  those  of 
the  solid  renal  growths,  except  that  fluctuation  may  be  felt  in  it.  The  history 
is,  however,  often  of  longer  duration  than  is  the  case  in  solid  tumours,  which 
usually  prove  fatal  in  less  than  eighteen  months.  Occasionally  the  fluid  of  a 
hydronephrosis  is  discharged  by  the  ureter,  in  which  case  the  swelling  will, 
of  course,  vary  in  size. 

Treatment. — Hydronephrosis  should  be  treated  by  incision,  which  is  best 
performed  in  the  lumbar  region.     The  fluid  which  escapes  has  usually  the 


6o2  Diseases  of  the  Genito-urinary  System 

characters  of  clear  dilute  urine.  The  kidney  should  be  drained  for  some 
time,  and  only  after  failure  of  this  treatment  should  nephrectomy  be 
thought  of. 

Renal  Calculus. — Stone  in  the  kidney  is,  like  stone  in  the  bladder,  a  dis- 
ease much  more  commonly  met  with  in  some  localities  than  in  others  ;  it  is, 
however,  apparently  relatively  rare  in  children,  and  when  it  does  occur  it  is 
seldom  that  the  symptoms  are  as  severe  or  characteristic  as  they  are  in  the 
case  of  adults.  It  appears  that  the  majority  of  calculi  formed  in  the  kidney  in 
children  pass  down  to  the  bladder  without  giving  rise  to  any  severe  symptoms 
of  renal  colic.  Should,  however,  a  stone  form  in  the  kidney  and  be  retained 
there,  it  may  give  rise  to  pain,  local  and  radiating,  pyuria,  frequent  mictu- 
rition, tenderness  on  pressure  over  the  kidney,  with  rigidity  of  the  lumbar 
muscles,  retraction  of  the  testis,  vomiting,  and  above  all  to  hsematuria  :  this 
last  is  the  most  characteristic  symptom  of  calculus,  and  in  the  absence  of 
nephritis  renal  htematuria  is  probably  due  to  calculus,  though  occasionally 
intermittent  ha;maturia  is  met  with  without  there  being  any  proof  of 
the  presence  of  a  stone.  We  have  only  on  two  or  three  occasions  had 
to  perform  nephro-lithotomy  in  children.  They  recovered  satisfactorily  from 
the  operation. 

In  a  few  cases,  if  the  disease  goes  on,  pyo-nephrosis  may  be  set  up,  and 
the  kidney  will  then  form  a  tumour  perceptible  to  the  touch. 

Tf^eatjnent. — Should  medicinal  treatment,  which  is  the  same  as  that  for 
tubercular  nephritis,  fail  to  give  relief,  the  kidney  should  be  exposed  by  the 
lumbar  incision  and  explored  by  puncture  with  a  needle  ;  if  the  calculus  is 
struck,  a  director  is  passed  along  the  needle,  and  the  kidney  opened  along 
its  convex  surface  and  the  calculus  removed.  If  the  needle  fails  to  find  the 
stone,  the  kidney  should  be  carefully  explored  with  the  finger,  both  by 
palpation  upon  the  surface  and  subsequently  by  opening  the  pelvis  and 
examination  with  the  finger  and  with  sounds.  Any  calculus  found  should 
be  removed  and  a  drainage  tube  passed  up  to  the  surface  of  the  kidney. 
The  wound  is  then  treated  on  ordinary  principles,  the  tube  being 
gradually  shortened.  If  the  kidney  is  healthy  and  the  ureter  patent, 
the  wound  will  probably  speedily  close  entirely  ;  if,  however,  the  ureter 
is  blocked,  or  there  is  much  destruction  of  the  kidney,  discharge  may  go 
on  indefinitely,  and  it  may  be  necessary  to  remove  the  organ  in  order  to 
obtain  healing  of  the  wound.  Before  nephrectomy  is  thought  of,  however, 
care  must  be  taken  to  ascertain  that  the  other  kidney  is  capable  of  doing 
sufficient  work.  For  further  particulars  we  must  refer  to  the  works  of  Morris, 
Bruce  Clarke,  and  Newman  ;  also  to  papers  by  one  of  the  present  writers  in 
the  'Medical  Chronicle'  for  1886-7-9-94. 

Acute  pyelitis  is  certainly  not  a  common  disease  in  infants  or  children. 
We  have,  however,  seen  several  cases  of  acute  illness  in  infants  or  young 
children  accompanied  by  a  high  temperature  of  an  intei'mittent  type,  and 
after  the  attack  has  lasted  several  days  it  has  been  noted  that  the  urine 
contained  pus  ;  the  nurse  having  called  attention  to  the  fact  that  there 
was  something  unusual  in  the  way  in  which  the  urine  stained  the  diapers. 
Dr.  S.  J.  Gee  has  recorded  a  similar  case  in  an  infant  of  nine  months. 
Dr.  Emmett  Holt  records  three  such  cases  in  infants  of  eight  months,  nine 
months,  and  fourteen  months  respectively.     The  temperature  in  one  of  his 


Renal  Calailus— Acute  Nephritis  603 

cases  ran  high,  and  there  were  distinct  'chills'  in  which  the  infant  became 
blue. 

What  is  the  exact  nature  of  these  cases,  and  whether  the  pyehtis  is 
primary  or  secondary  to  some  other  chsease,  it  is  difficult  to  say.  All  the 
recorded  cases  ended  in  recovery. 

ii.cute  Nephritis. — Acute  inflammation  of  the  kidneys  occurs  much  less 
freciuently  as  a  primary  than  as  a  secondary  disease.  The  kidneys  are 
fortunately  not  so  prone  to  take  on  inflammation  as  the  lungs,  possibly 
because  they  are  less  exposed  to  cold  and  they  are  out  of  reach  of  the 
micro-organisms  present  in  the  air. 

Acute  nephritis  does,  however,  occur  as  a  primary  disease,  or  at  any  rate 
in  patients  who,  as  far  as  can  be  ascertained,  have  not  suffered  from  any  ante- 
cedent disease,  and  who  were  in  perfect  health  up  to  the  time  of  the  attack. 
Thus  we  find  a  schoolboy,  who  has  never  had  scarlet  fever  and  been  in  good 
health,  have  a  shivering  fit,  an  evening  rise  of  temperature,  followed  by  the 
passage  of  albuminous  and  perhaps  dark  urine,  and  pass  through  the  stages 
of  a  typical  attack  of  acute  nephritis.  In  other  cases  the  onset  is  more 
insidious,  and  the  first  thing  noticed  is  a  pale  and  puffy  face.  But  in  all  cases 
in  which  the  urine  contains  blood  as  well  as  albumen  and  casts,  we  should 
be  suspicious  of  antecedent  scarlet  fever,  though  possibly  a  very  mild  attack. 
In  rare  cases  acute  nephritis  occurs  during  infancy  apparently  as  a  primary 
disease  ;  and  it  is  needless  to  say  that  it  may  be  readily  overlooked,  as  the 
urine  of  infants  is  not  often  examined  unless  special  attention  is  called  to  it 
on  account  of  its  staining  the  napkin.  If  there  is  associated  broncho-pneu- 
monia or  gastro-intestinal  disturbance,  it  is  still  more  likely  to  be  overlooked. 
The  difficulty  of  diagnosis  in  such  cases  is  not  always  overcome  by  a  post- 
mortem examination,  inasmuch  as  we  may  find  pale  kidneys  with  more  or 
less  marked  parenchymatous  changes  in  infants  who  have  died  of  enteritis, 
septic  pneumonia,  and  other  acute  diseases.  It  is  by  no  means  easy  always 
to  say,  when  sections  of  kidney  are  examined  microscopically,  whether  such 
changes  as  desquamation  of  the  epithelium  are  pathological  or  accidental,  or 
whether  there  is  slight  proliferation  of  the  epithelium  or  not. 

Reference  has  already  been  made  to  acute  nephritis  (p.  257)  when  speak- 
ing of  scarlet  fever,  as  acute  nephritis  occurs  more  frequently  during  con- 
valescence from  this  fever  than  after  any  other  disease.  It  is  well  to  bear  in 
mind,  however,  that  nephritis  may  occur  after  some  other  febrile  states,  such 
as  diphtheria,  croupous  pneumonia,  varicella,  typhoid  fever,  vaccinia,  and 
eczema.  These  febrile  conditions  appear  to  give  rise  to  an  irritable  state  of 
tFe  kidneys  and  render  them  liable  to  take  on  an  acute  inflammatory  state. 
It  must  not  be  forgotten  that  nephritis  may  follow  mild  attacks  of  scarlet 
fever  ;  the  primary  fever  may  have  been  overlooked  by  the  friends,  especially 
if  the  latter  are  unobservant  or  ignorant  ;  and  in  any  patient  coming  under 
notice  for  the  first  time,  suffering  from  acute  nephritis,  the  history  of  the  case 
should  be  carefully  inquired  into  and  the  child's  skin  examined  for  any  traces 
of  desquamation. 

In  the  following  case  acute  nephritis  supervened  during  an  attack  of 
croupous  pneumonia. 

Croupous  P72cu?noma,  Acute  Nephritis. — George  H.,  aged  4  years. 
March   18  was  sick  and   feverish  ;  admitted    March   20.     There  was  well- 


6o4  Diseases  of  the  Genito-uidnary  System 

marked  dulness  and  bronchial  breathing  at  the  left  apex,  both  in  front  and 
behind.  P.  loo  ;  R.  60 ;  T.  103°;  urine  jJgth  albumen.  March  21. — T.  104°, 
much  dyspnoea ;  only  8  oz.  of  urine  passed,  which  contains  much  blood  and 
albumen.  March  24,  only  i  oz.  of  urine  passed  in  last  twenty-four  hours,  much 
blood  and  albumen.  Vomiting.  T.  104°.  After  this  date  he  improved,  the 
temperature  fell  April  4,  and  recovery  ensued. 

Acute  nephritis  occurring  during  convalescence  from  scarlet  fever,  or  as  a 
primary  disease,  is  usually  an  inflammatory  lesion  of  the  croupous  pneumonia 
type.  There  is  an  inflammatory  engorgement  of  the  blood  vessels  with  fever 
of  an  intermittent  type,  and,  as  a  result,  a  choking  of  the  tubules  by  the 
exudation  of  liquor  sanguinis,  and  usually  of  blood  corpuscles.  As  a  conse- 
quence of  this  the  urine  is  scanty  and  contains  fibrinous  casts,  blood  corpus- 
cles, albumen,  and  much  epithelial  debris.  In  the  less  acute  cases  there  is 
not  sufficient  blood  present  to  discolour  the  urine.  If  the  inflammatory 
condition  fails  to  be  relieved,  secondary  changes  occur,  the  most  important 
of  which  consists  in  a  glomerular  or  periglomerular  nephritis.  The  glomeruli 
become  enlarged  in  consequence  of  a  hyperplasia  of  their  endothelial  nuclei 
(Friedlander),  or  in  other  cases  a  fibro-cellular  growth  takes  place  between 
the  glomerulus  and  the  capsule  of  Bowman  ;  in  either  case  the  result  is  the 
same — namely,  an  obstruction  to  the  flow  of  blood  through  the  glomerulus. 
Changes  in  the  epithelium  also  take  place.  As  these  changes  progress  the 
urine  becomes  more  and  more  scanty,  and  death  takes  place  from  either 
cardiac  failure,  uraemia,  or  some  inflammation  of  a  serous  membrane. 

The  symptoms  and  treatment  have  already  been  discussed  (pp.  258  and 
265),  and  little  need  be  added  here.  It  is  well  to  bear  in  mind  that  cases  of 
very  different  severity  may  he  met  with  :  in  some  cases  the  engorgement  of 
the  kidney  is  extreme,  and  variable  quantities  of  urine  are  passed,  containing" 
large  quantities  of  blood  and  albumen.  In  other  cases  there  may  be  marked 
anfemia,  much  general  cedema,  scanty  urine,  with  no  albumen  or  only  a  trace, 
and  we  may  be  left  in  doubt  if  the  case  is  really  one  of  nephritis  or  whether 
the  oedema  is  simply  due  to  a  watery  state  of  the  blood.  This  class  of  case 
is  not  uncommon  in  young  children  under  three  years  who  have  recently 
suffered  from  some  acute  disease,  such  as  acute  diarrhoea  or  pneumonia  ;  the 
pallor  and  oedema  present  suggest  acute  nephritis,  but  an  examination  of 
the  urine  possibly  gives  negative  results  as  far  as  albumen  is  concerned. 
In  some  of  these  cases  we  have  failed  to  find  any  evidence  of  nephritis  on  a 
microscopical  examination  of  the  kidneys.  Acute  or  subacute  attacks  of 
nephritis  do,  however,  occur  in  young  children.  The  first  symptom  is  mostly 
oedema  of  the  face,  the  cedema  becoming  general.  It  is  often  associated 
with  broncho-pneumonia,  and  tends  to  a  fatal  issue. 

Septic  irephritis  has  been  also  referred  to  under  the  complications  of 
scarlet  fever  (p.  258).  It  is  well,  however,  to  bear  in  mind  that  such  cases 
occur  after  other  febrile  states.  We  have  seen  a  condition  of  the  kidneys 
answering  this  description  occurring  apparently  primarily,  but  we  have  always 
had  our  suspicions  that  some  cause  must  have  been  overlooked. 

Acute  Toxic  Nephritis,  Parenchymatous  nephritis. —  In  diphtheria, 
malignant  endocarditis,  zymotic  diarrhoea,  and  any  disease  in  which  there  is 
ptomaine  poisoning,  there  is  albuminuria,  and  certain  changes  in  the  kidney 
are  found  after  death.     This  is  specially  so  in  diphtheria.     We  have  already 


Acute   Toxic  Nephritis — Chronic  Nephritis  605 

referred  to  the  albuminuria  which  so  frequently  occurs  in  the  course  of  this 
disease,  and  also  to  the  fact  that  in  some  cases,  especially  in  the  malignant 
ones,  the  urine  becomes  more  and  more  loaded  with  albumen  while  becoming 
more  scanty,  and  complete  anuria  may  take  place  twenty-four  hours  or  forty- 
eight  hours  before  death.  Unlike  scarlatinal  nephritis  there  is  rarely  oedema, 
muscular  twitchings,  or  urtEmic  convulsions,  but  coma  usually  precedes  death. 
On  posf-viortein  examination  of  the  kidneys  of  those  dying  from  diphtheria,  in 
most  cases  the  kidneys  will  be  found  to  be  hypcra^mic  and  slightly  enlarged, 
the  cortex  being  pale,  the  medullary  portions  congested.  The  principal 
microscopical  changes  occur  in  the  epithelial  cells,  which  are  swollen  and 
granular.  A  few  fibrin  cylinders  and  blood  cylinders  are  sometimes  present. 
No  very  marked  changes  sufficient  to  account  for  complete  anuria  have  been 
found  in  the  kidneys  of  those  dying  with  total  suppression  of  urine.  It  is 
possible,  as  has  been  sugg'ested,  that  the  anuria  is  due  to  a  peripheral  neuritis 
of  the  abdominal  sympathetic,  or  that  portion  of  the  system  which  regulates 
the  local  tension  of  blood  in  the  capillaries  of  the  kidneys. 

Chronic  Nephritis. — We  cannot  too  strongly  emphasise  the  necessity 
of  examining  the  urine  from  time  to  time  of  children  who  have  recently  had 
scarlet  fever,  especially  if  they  have  suffered  from  scarlatinal  nephritis.  It 
is  not  enough  to  find  that  on  one  or  two  occasions  the  urine  is  free  from 
albumen  in  order  to  declare  them  well.  Nephritis,  however  mild,  renders 
the  kidneys  liable  to  attacks,  and  these  subsequent  attacks  may  readily  pass 
into  a  chronic  nephritis  in  which  organic  changes  take  place  and  irretrievable 
damage  is  done.  There  may  be  an  albuminuria  which  is  intermittent,  and 
in  consequence  a  slight  kidney  affection  is  liable  to  be  overlooked.  We 
have  already  referred  to  cases  in  children  who  have  suffered  from  nephritis 
and  who  were  apparently  quite  well  pass  urine  free  from  albumen  during  the 
night  or  when  they  were  kept  in  bed,  but  albumen  at  once  appeared  in  the 
urine  when  they  got  up,  and  especially  if  they  went  out  of  doors.  In  such 
cases  an  acute  attack  is  readily  set  up,  with  attendant  anaemia  and  dropsy. 
The  history  of  a  chronic  nephritis  is  the  history  of  a  series  of  acute  or 
subacute  attacks,  followed  by  a  period  of  apparent  health  perhaps  extending 
over  many  years.  No  doubt  in  a  certain  proportion  of  cases  recovery  even- 
tually takes  place,  but  in  others  the  kidneys  become  hopelessly  damaged  by 
fatty  and  fibroid  changes,  and  they  eventually  succumb.  In  many  of  these 
cases  the  progress  is  exceedingly  insidious  ;  it  is  only  when  the  friends  have 
their  attention  called  to  the  pufify  face  or  oedema  of  the  feet  that  medical 
advice  is  obtained. 

In  some  instances  we  have  known  schoolboys  who  had  apparently  been 
in  good  health  noticed  by  their  house  master  to  look  '  puffy '  in  the  face, 
and  on  medical  examination  large  quantities  of  albumen  are  found  in  the 
urine.  There  has  been  no  history  of  scarlet  fever  and  no  marked  symptoms 
till  the  cedema  has  been  noticed.  In  these  insidious  cases  of  subacute 
nephritis  the  prognosis  is  mostly  bad  ;  there  is  a  course  perhaps  of  three 
months  to  two  years,  but  rarely  complete  restoration  to  health. 

In  a  typical  case  of  subacute  or  chronic  nephritis  the  appearance  of  the 
patient  at  once  establishes  the  diagnosis— the  bloated,  puffy,  pallid  face  is 
characteristic.  The  abdomen  is  distended,  being  tympanitic  over  the  air- 
containing  intestines  and  stomach,  dull  and  fluctuating  in  the  flanks  from 


6o6  Diseases  of  the  Genito -urinary  System 

the  presence  of  fluid.  The  scrotum  is  oedematous,  the  skin  everywhere  pits 
on  pressure,  especially  on  the  dorsum  of  the  feet.  There  is  frequently 
headache  and  vomiting  or  nausea.  The  pulse  is  usually  slow  and  of  high 
tension,  but  in  children  the  high-tension  pulse  of  Bright's  disease  is  less 
marked  than  in  adults.  The  heart  cavities  become  dilated,  the  apex  beat  is 
diffused  and  tends  to  become  displaced  outwards  beyond  the  left  nipple 
line.  Possibly  the  urine  is  scanty,  contains  many  casts,  and  is  loaded  with 
albumen.  Gradual  improvement  takes  place  till  the  patient  is  fairly  well 
again,  and  the  urine  free,  or  nearly  free,  from  albumen.  In  other  cases  they 
remain  for  months  in  practically  the  same  condition,  the  amount  of  albumen 
and  dropsy  varying  from  time  to  time.  Gradually  perhaps  there  is  .increasing 
dropsy,  so  that  the  patient  becomes  waterlogged.  The  face,  lower  extremi- 
ties, and  scrotum  are  extremely  cedematous,  and  the  peritoneal  cavity 
distended  with  fluid,  while  the  sickness  is  very  distressing.  Dyspnoea  is 
usually  a  marked  symptom,  and  the  patient  has  to  be  propped  up  in  bed. 
Finally  the  patient  lapses  into  coma,  which  marks  the  beginning  of  the 
end.  The  urine  is  often  reduced  in  amount  to  one  or  two  ounces  in  twenty- 
four  hours.     Ura;mic  convulsions  are  common  at  the  last. 

In  such  cases  a  'large  -white  kidney'  is  found /^j-/  mortem;  sometimes 
the  kidneys  are  enormously  enlarged.  In  one  of  our  cases  (a  girl  of  twelve 
years)  the  two  kidneys  weighed  together  22|  ounces,  and  one  measured  six 
inches  in  length.  Such  kidneys  show  the  epithelium  infiltrated  with  fatty 
drops,  and  various  fibroid  changes,  especially  around  the  glomeruli,  many 
of  the  glomeruli  having  been  strangulated  by  a  surrounding  fibroid  growth. 
The  heart  is  hypertrophied. 

The  '  granular  contracted  kidney  '  is  rare  in  children  ;  we  have  seen 
at  least  five  cases — three  occurred  in  girls,  aged  ii^  years,  lo^  years,  and 
7  years  respectively — and  two  in  boys  aged  12  years  and  4  years  11  months. 
In  the  first  case  there  was  only  a  history  of  two  or  three  weeks'  illness 
before  admission  to  hospital,  but  the  history  was  imperfect ;  she  had  never 
had  scarlet  fever  ;  when  admitted  there  was  much  oedema  and  dyspnoea ;  the 
urine  was  of  sp.  gr.  1015,  containing  half  albumen — she  passed  800-1000  c.c. 
daily.  At  \}i\&  post-mortem  the  right  kidney  weighed  2\  oz.  and  the  left  |  oz. 
The  left  was  a  mere  vestige  of  a  kidney  ;  the  capsule  of  the  right  was  ad- 
herent, the  surface  granular,  the  cortex  was  narrow,  and,  in  short,  the  kidney 
was  an  extreme  example  of  a  granular  contracted  one.  The  ureters  were 
dilated.  The  heart  weighed  8  oz.,  the  walls  of  the  left  ventricle  were  much 
hypertrophied. 

A  second  case  (girl  10^  years)  was  admitted  to  a  surgical  ward  for 
rickety  deformity  of  the  tibia.  There  was  a  history  for  two  years  before 
of  thirst,  headaches,  and  frequent  passage  of  urine,  especially  at  night.  On 
admission  there  was  urgent  dyspnoea,  for  which  no  cause  could  be  found  ; 
she  gradually  passed  into  an  unconscious  state,  and  died  twenty-four  hours 
after  admission.  No  urine  was  obtained,  she  having"  passed  it  into  bed. 
At  the  po»t-mortem  the  kidneys  were  typically  granular  and  contracted  ; 
they  together  weighed  i^  oz.  only,  and  measured  two  inches  in  length  ;  the 
capsules  were  adherent,  the  surface  granular,  and  the  cortex  surface  wasted  ; 
the  heart  weighed  8|  oz.  and  the  left  ventricular  walls  were  thickened. 

In  the  third  case,  that  of  a  boy  aged  12  years,  it  was  uncertain  if  he 


Chronic  yep/iritis — Addison's  Disease  607 

had  had  scarlet  fever  ;  he  had  measles  at  three  years  of  age  which  had  left 
liini  deaf  in  one  ear.  For  three  months  before  death  he  had  suffered  from 
frontal  headaches  and  had  been  thirsty.  A  month  before  death  he  had 
untMTiic  convulsions,  which  continued  at  intervals.  Only  one  or  two  specimens 
of  urine  were  obtained;  the  excretion  was  free,  S.G.  loio,  much  albumen. 
Coma  supervened  twenty-four  hours  before  death.  There  never  was  any 
oedema.  Post-mortem  :  typical  granular  kidneys  weighing  i|  oz.  each  ;  heart 
8  oz.,  hypertrophy  of  the  left  ventricle,  thickening  of  the  mitral  valves, 
atheroma  of  the  aorta  and  thickening  of  the  aortic  valves. 

A  fourth  case,  a  boy  aged  4  years  1 1  months  was  admitted  to  hospital 
for  genu  valgum.  No  albumen  was  found  in  the  urine.  He  was  operated 
on,  and  a  day  or  two  after  the  operation  he  became  drowsy.  There  was  no 
fever,  convulsion,  or  twitching  ;  he  died  comatose  eight  days  after  operation. 
There  was  albumen  in  his  urine  shortly  before  death.  At  the  posi-nwrteiii 
made  by  Mr.  Woodhouse,  the  kidneys  were  found  small  and  shrivelled, 
weighing  together  2  oz.,  the  capsule  was  adherent,  the  surface  irregular,  not 
granular  and  pale.  On  section,  the  cortex  was  pale  and  much  wasted,  the 
calyces  of  the  pelvis  much  dilated.  The  kidneys  were  undoubtedly  wasted 
and  shrivelled,  but  not  typically  granular. 

In  another  case  (patient  of  Drs.  Fawsitt  and  Godson),  a  girl  of  7  years 
old  was  never  strong  from  her  birth  and  had  more  or  less  incontinence  of 
urine  all  her  life.  For  a  year  before  death  she  was  anaemic  and  easily  out 
of  breath  on  exertion.  When  seen  some  months  before  her  death  there  was 
^2  albumen  (by  vol.),  the  cardiac  area  was  enlarged  towards  the  left,  but  the 
apex  beat  was  just  inside  the  nipple  line.  There  was  a  bruit  heard  at  apex 
and  base.  The  spleen  was  enlarged.  The  anaemia  increased  and  oedema 
supervened.  At  the  autopsy  small  white  granular  kidneys  were  found ;  the 
larger  of  the  two,  which  Dr.  Godson  kindly  forwarded  to  us,  weighed  \  oz.  ; 
the  left  ventricular  wall  was  hypertrophied,  the  cavity  not  dilated. 

Treatment. — In  chronic  albuminuria  the  patient  must  be  rigidly  pro- 
tected frorn  cold,  as  the  least  chill  is  liable  to  lead  to  an  acute  attack.  Bed 
is  the  best  place  as  long  as  albumen  is  present  in  the  urine.  A  simple  un- 
stimulating  diet  is  necessary,  milk  forming  the  staple  food,  with  arrowroot, 
ground  rice,  or  other  light  puddings.  Meat  is  best  avoided  as  long  as  the 
urine  is  albuminous.  When  oedema  is  present  and  the  urine  scanty,  hot 
air  or  vapour  baths  should  be  given  daily,  while  the  kidneys  are  acted  on 
by  salines,  such  as  tartrate  of  potash,  diuretics,  digitalis,  or  squills.  During 
convalescence  tr.  ferri  acetatis  may  be  given  with  digitalis.  Vomiting  is 
best  treated  by  saline  purgatives  and  peptonised  milk  gruel  in  small  quantities. 
Nitro-pilocarpine  in  ^V  gr.  doses  by  the  mouth  seems  often  to  relieve.  In 
anaemic  convulsions  injections  of  morphia,  x'tj-B  gi'-,  a-i'e  useful  and  may  be 
given  without  risk  (see  also  F.  91,  92,  93,  and  94). 

Addison's  Disease.  Tuberculosis  of  the  Adrenals. ^ — Addison's 
disease  occurs  occasionally  in  children  after  puberty  ;  it  is  very  rare  before 
this  epoch.  Dr.  Pye  Smith  has  recorded  a  case  in  a  boy  of  fourteen  years, 
and  Monti  has  collected  eleven  cases  in  children  from  three  to  fourteen  years 
of  age.  Tubercules,  both  caseous  and  grey,  are  frequently  present  in  the 
suprarenal  capsules  of  children  dying-  from  general  tuberculosis,  without 
any  symptoms  occurring  during  life. 


6o8  Diseases  of  the  Genito-urinary  System 

Dr.  J.  S.  Bury  has  recorded  a  well-marked  case  in  a  girl  of  thirteen  years 
of  age.  The  early  symptoms  were  those  of  gastric  disturbance  and  vomiting, 
which  continued  throughout  her  illness,  which  lasted  twelve  months.  Her 
skin  gradually  became  discoloured,  all  the  parts  of  the  body  being  of  a 
brown  colour.  She  gradually  wasted  and  died  of  exhaustion.  The  adrenals 
were  found  adherent  to  the  fatty  tissue  which  surrounds  them  and  to  the 
diaphragm  ;  on  section  they  showed  caseous  and  fibroid  changes.  There 
was  no  tuberculosis  elsewhere. 


6og 


CHAPTER    XXVIII 

DISEASES    OF   THE   GENITO-URINARY   SYSTEM — continued 

Stone  in  the  Bladder  in  children  is,  as  in  adults,  a  much  more  common 
disease  in  some  localities  than  in  others.  It  may  occur  at  any  age,  and  a 
congenital  case  even  has  been  recorded.  The  symptoms  vary  much  in 
severity  ;  sometimes  but  little  pain  or  trouble  is  caused  by  the  stone,  at  other 
times  the  distress  is  constant  and  severe.  The  causation  of  calculus  need 
not  be  discussed  :  there  is  little  evidence  that  any  particular  diet  has  any 
active  share  in  producing  it. 

Symptoms. — There  is  usually  pain  referred  to  the  end  of  the  penis,  or  to 
the  hypogastrium  or  perinsum  ;  the  pain  is  most  severe  towards  the  end  of 
micturition,  but  when  there  is  cystitis  it  is  nearly  constant.  Passage  of  blood 
in  the  urine,  usually  at  the  end  of  micturition,  is  a  very  frequent  though  not 
absolutely  constant  sign  ;  frequent  micturition  and  inability  to  retain  the 
urine  are  almost  always  present.  The  straining  efforts  to  empty  the  bladder 
often  give  rise  to  prolapse  of  the  rectum  and  hernia.  An  elongated,  ex- 
coriated prepuce,  the  joint  result  of  the  irritating  quality  of  the  urine,  of 
frequent  micturition,  and  of  pulling  at  the  penis  to  relieve  the  irritation  felt  at 
the  end  of  the  organ,  is  usually  seen.  The  urine  is  muddy,  containing  pus  and 
phosphates  jn  varying  quantity  ;  if  no  cystitis  is  present,  it  may,  however,  be 
quite  clear.  On  sounding,  the  stone  is  usually  felt  at  once  ;  it  is  rare  to  find  a 
stone  in  children  that  is  not  struck  by  the  instrument  as  it  enters  the  bladder, 
but,  as  this  is  not  always  so,  if  the  other  signs  of  stone  are  present,  repeated 
soundings  should  be  made  if  the  calculus  is  not  found  at  once. 

E.  Owen  suggests  that  sometimes  the  stone  may  be  lodged  in  the  orifice 
of  one  ureter  :  but,  though  Dr.  Cullingworth  and  others  have  recorded  such 
cases  in  adults,  we  do  not  know  of  an  instance  of  this  in  childhood. 

The  most  common  variety  of  calculus  in  children  is  the  uric  acid  ;  next 
perhaps,  comes  the  form  consisting  of  urates  ;  if  the  stone  has  caused  cystitis, 
there  may  of  course  be  a  phosphatic  coating,  or  the  whole  calculus  may  be 
phosphatic.  Ebstein  believes  that  the  uric  acid  infarcts  of  newly  born 
children  form  the  first  stage  in  calculus  production,  and  that  the  large 
cjuantity  of  uric  acid  present  in  foetal  and  early  life  explains  the  frequency  of 
calculi  of  this  substance  (' Centralblatt  f.  Chirurg.'  No.  14,  1885).  The 
abnormal  eUmination  of  uric  acid  leads  to  degeneration  of  epithelium,  which 
forms  the  animal  basis  of  the  calculus. 

Calculi  in  children  vary  much  in  size  :  that  is  to  say,  that  as  different 
calculi  give  rise  to  varying  degrees  of  distress,  some  of  them  are  allowed 

R  R 


6io  Diseases  of  the  Genito-urinary  System 

to  reach  a  larger  size  before  the  child  is  brought  for  treatment  than  are 
others. 

In  shape  the  calculi  are  usually  oval  and  flattened  (uric  acid),  but  spindle- 
shaped  stones  are  often  met  with  :  such  are  those  which,  while  small,  so 
frequently  pass  into  the  urethra,  and,  becoming  impacted,  give  rise  to  re- 
tention of  urine.  Thus  one  of  these  small  oat-shaped  calculi  some  day  comes 
to  lie  with  one  end  projecting  into  the  urethra,  violent  straining  to  pass  urine 
takes  place,  and  the  calculus  is  washed  along  the  urethra  and  usually  becomes 
fixed  just  within  the  meatus  at  the  fossa  navicularis,  since  the  meatus  is  the 
narrowest  part  of  the  urethra.  In  other  cases  the  stone  is  arrested  at  the  bulb 
or  in  the  penile  poi'tion  of  the  tube.  The  symptoms  of  such  an  occurrence  are 
pain,  CEdema  of  the  part,  retention  of  urine,  and  tenesmus  ;  on  examination 
the  stone  can  usually  be  felt  through  the  urethral  wall,  or  is  readily  struck  on 
passing  a  sound  or  probe  into  the  urethra.  If  the  case  is  neglected,  ulcera- 
tion may  take  place  and  extravasation  of  urine  :  this  sometimes  occurs  very 
rapidly.  We  have  seen  fatal  extravasation  come  on  in  a  few  hours.  When 
this  occurs  the  symptoms  are  the  same  as  in  an  adult  :  pain,  swelling  of  the 
perinaeum,  scrotum,  and  penis,  constitutional  disturbance,  and,  failing  relief, 
rapid  sloughing  of  the  tissues.  In  all  cases  of  retention  of  urine  in  a  child,  if 
phimosis  will  not  account  for  the  inability  to  empty  the  bladder,  impacted 
calculus  should  be  suspected.  The  secondary  effects  of  calculus  are  cystitis, 
pyelitis,  and  suppurative  nephritis.  The  ureters  may  become  dilated  and 
inflamed  by  extension  of  mischief  from  the  bladder  ;  and  obstruction  to  the 
outflow  of  urine,  suppurative  pyelitis,  and  subsequent  extension  of  suppura- 
tion along  the  renal  tubes  and  in  the  peritubular  tissue  may  result.  This  is 
probably  not  always  fatal,  and  on  removal  of  the  stone  the  kidney  mischief 
may  subside  :  nevertheless  the  injury  so  done  to  the  kidneys  may  be  one  of 
the  reasons  why  children,  the  subjects  of  stone,  seldom  seem  to  grow  up, 
though  the  mortality  from  lithotomy  is  so  small  in  childhood  ;  it  is,  as 
Mr.  Erichsen  says,  very  rare  to  see  an  adult  who  has  been  cut  for  stone  in 
childhood. 

Diagnosis.— OnG  or  more  of  the  symptoms  of  stone  may  be  caused  by 
many  other  conditions  :  worms,  phimosis,  a  contracted  meatus  urinarius, 
simple  or  tubercular  cystitis,  the  so-called  irritable  bladder,'  vesical  tumours, 
and  renal  calculus,  all  may  simulate  stone  in  the  bladder  to  a  certain  extent  ; 
the  diagnosis  is  only  to  be  certainly  made  by  sounding.  Stones  can  often 
be  felt  by  bimanual  palpation,  one  finger  being  passed  into  the  rectum  and 
the  other  hand  pressed  down  above  the  pubes. 

Treatment. — Until  recent  times  lateral  lithotomy  has  been  practically 
always  the  mode  adopted  for  removal  of  a  vesical  calculus  in  boys,  and  its 
success  is  so  great  that  but  little  attempt  has  until  lately  been  made  to  find 
any  other  treatment.  Median  lithotomy  is  little  applicable,  on  account  of 
the  small  size  of  the  parts.  Of  late  the  operations  of  litholapaxy  and  supra- 
pubic lithotomy  have  both  been  employed  in  children.  Keegan,  in  the 
'Indian  Medical  Gazette,'  May  1884  {vide  also  '  Lancet,'  vol.  ii.  1886  and 
1890),-  collected  over  one  hundred  cases  of  lithotrity  in  children  between 

1  Thus,  for  instance,  hsematuria  may  result  from  phimosis  and  consequent  irritable 
bladder  (Bryant),  and  also  may  be  due  to  tuberculous  cystitis.     See  also  p.  194. 

2  Also  Southam,  Med.  Chron.  vol.  xii.  1890. 


Stone  in  tJic  Bladder  6 1 1 

the  ages  of  one  and  a  half  and  eleven  years  ;  among  these  there  were  three 
deaths  ;  in  six  cases  the  stone  was  allowed  to  escape  with  the  urine  after 
crushing,  in  the  rest  it  was  evacuated ;  the  size  of  the  calculi  varied  from  five 
grains  to  four  drams.     The  operation  has  since  been  largely  used. 

It  is  now  well  established,  chiefly  by  the  work  of  Keegan  and  Freyer  in 
India,  that  the  urethra  of  a  child  of  three  or  four  years  will  readily  admit  a 
No.  8  lithotrite  after  slitting  the  meatus,  and  we  have  found  no  difficulty 
whatever,  as  far  as  this  goes,  in  the  cases  in  which  we  have  tried  it  ;  such 
an  instrument  is  abundantly  powerful  for  the  vast  majority  of  stones  we 
find  in  children,  and  there  seems  no  valid  reason  against  lithotrity  on  this 
ground.  In  one  of  our  cases,  however,  the  lithotrite  broke  in  the  child's 
bladder,  and  was  removed,  together  with  the  stone,  by  suprapubic  lithotomy. 
This  child  died  of  bronchitis  shortly  after.  The  death  was  clearly  the  result 
of  the  somewhat  prolonged  operation  and  exposure.  Freyer  even  says  that 
a  No.  6  cannula  maybe  readily  passed  into  a  child  under  one  year  old,  though 
this  is  not  always  the  case.  In  our  own  cases  there  was  some  difficulty  in 
seizing  the  stone,  but  this  was  got  over  m  one  case  by  passing  a  finger  into 
the  rectum  and  lifting  the  stone  between  the  blades  of  the  lithotrite.  The 
operation,  in  this  instance,  was  followed  by  pysemia,  and  the  child  died  ; 
after  pysemia  had  developed  it  was  found  that  a  second  stone  existed,  and 
this,  being  lodged  in  the  neck  of  the  bladder,  was  removed  by  median  litho- 
tomy, but  the  pyeemia  was  in  no  way  improved.  We  do  not,  however,  look 
upon  this  case  as  any  argument  against  lithotrity,  though  it  must  be  remem- 
bered that  the  natives  of  India  bear  surgical  operations  far  better  than 
Europeans,  provided  no  bone  lesion  is  present.  In  our  case  kidneys  and 
ureters  were  both  diseased,  and  probably  this  condition  largely  contributed 
to  the  fatal  result.  Though  the  cases  we  have  mentioned  show  that  litho- 
trity in  children  is  not  without  its  difficulties  and  dangers,  we  have  no  doubt 
from  our  own  experience  that  it  is  the  proper  operation  to  perform  in  cases 
where  the  stone  is  small  or  of  moderate  size,  and  the  child  is  not  too  weakly 
to  bear  an, often  necessarily  prolonged  manipulation.  In  any  case  a  well- 
fenestrated  lithotrite  is  essential,  as  detritus  is  apt  to  become  jammed  in 
the  blades,  and  thus  to  prevent  the  withdrawal  of  the  instrument  without 
difficulty.  We  have  had  to  open  the  urethra  and  protrude  and  clear  the 
lithotrite  before  it  could  be  withdrawn  through  the  front  part  of  the  passage. 

As  to  the  suprapubic  operation,  there  is  much  to  be  said  both  for  and 
against  it.  Against  it  is  the  risk  of  wounding  the  peritoneum,  the  risk  of 
urinary  infiltration,  and  the  fact  of  the  good  results  following  the  lateral 
operation.  In  favour  of  it  is  the  fact  that  the  operation  is  done  as  it  were  in 
the  open  :  there  is  no  cutting  in  the  dark,  no  risk  of  wounding  important 
structures  such  as  the  rectum,  pelvic  fascia,  and  seminal  ducts,^  while  injury 
to  the  peritoneum  is  only  likely  to  occur  exceptionally,  and  is  less  likely  in 
children  than  in  adults,  from  the  fact  that  in  children  the  bladder  is  an 
abdominal,  in  adults  a  pelvic  organ. 

Suprapubic  lithotomy  in  children  has,  as  shown  by  Sir  W^m.  MacCormac 
and  others,  a  very  small  mortality  ;  it  is  an  easy  operation,  and  requires  no 

1  Sir  Wm.  MacCormac  quotes  Haemstadt,  to  the  effect  that  of  eighteen  males  who  had 
been  Hthotomised  in  childhood,  and  had  grown  up  and  married,  only  one  had  children. — 
Lancet,  March  19,  1887. 

R  R  2 


6i2  Diseases  of  tJie  Genito-urmary  System 

skilled  assistance.  In  performing  the  operation  no  rectal  bag  should  be 
used  ;  the  bladder  should  be  injected  with  from  3  to  4  oz.  of  boric  lotion 
and  a  gradual  dissection  made  down  to  the  organ,  not  using  the  knife  after 
the  peri-vesical  fat  is  exposed.  A  staff  should  be  kept  in  the  bladder  during 
the  operation,  and  its  end  used  as  a  guide  upon  which  to  open  the  bladder  ; 
by  pushing  the  bladder  up  gently  with  the  staff,  and  opening  the  viscus  lower 
down,  all  risk  of  injury  to  the  peritoneum  is  entirely  avoided.  As  soon  as 
the  bladder  is  laid  bare,  two  sutures  are  passed  through  it,  and  the  organ  is 
opened  between  them,  the  stone  is  extracted  with  forceps  or  the  finger,  and 
the  wound  either |lleft  altogether  open  or  the  bladder  stitched  up,  the  super- 
ficial structures  being  left  quite  open.  Any  stitches  passed  through  the 
bladder  walls  should  not  include  the  mucous  membrane.  It  is  well  to  keep 
the  child  on  its  side  or  face  after  the  operation,  to  allow  free  drainage  away 
of  any  urine  that  may  collect  in  the  wound.  In  several  cases  (R.  W.  Parker 
and  others)  the  wound  has  united  by  first  intention,  but,  on  the  whole,  we 
think  it  better  to  leave  the  rest  of  the  wound  open  while  the  bladder  wound 
is  sutured,  or  perhaps  better  still  to  use  no  sutures  at  all.  The  operation 
has  largely  replaced  lateral  lithotomy,  but  further  experience  is  required. 
We  have  not  done  lateral  lithotomy  for  several  years,  all  cases  of  stone 
having  been  dealt  with  either  by  lithotrity  or  the  suprapubic  operation. 

It  is  unnecessary  here  to  describe  the  operation  of  lateral  lithotomy  ;  it 
will  be  sufficient  to  point  out  that  the  operation  in  children  differs  from  that 
in  adults  chiefly  in  that  in  childhood  the  field  of  operation  is  smaller,  not 
only  on  account  of  the  size  of  the  patient,  but  because  the  genital  organs  are 
undeveloped  and  the  prostate  exists  only  in  a  very  rudimentary  condition. 
It  is  usually  said  that  in  children  the  difficulty  of  the  operation  is  in  getting 
into  the  bladder,  in  adults  it  is  in  getting  the  stone  out.  This  arises  partly 
from  the  small  size  of  the  parts  already  mentioned,  partly  from  the  fact  that 
the  bladder  in  children  is  more  an  abdominal  than  a  pelvic  organ,  and  partly 
because  the  tissues  of  the  child  are  more  easily  lacerated  than  those  of  the 
adult,  and  very  gentle  manipulation  is  therefore  required.  In  lateral  lithotomy 
in  a  child  the  incision  is  usually  carried  through  the  whole  depth  of  the  pros- 
tate, instead  of  only  through  a  part  of  the  gland,  and  unless  the  opening 
into  the  bladder  is  fairly  free  there  is  a  risk  of  pushing  the  bladder  before 
the  finger  and  stripping  it  up  from  its  attachments,  or  even  of  tearing  across 
the  urethra.  The  only  other  point  requiring  remark  is  that  in  children  it  is 
often  easy  by  passing  a  finger  into  the  rectum  to  bring  the  stone  within  the 
^rasp  of  the  forceps,  or  even  to  extrude  it  from  the  perineeal  opening,  and 
this  is  still  further  facilitated  in  some  instances  by  pressure  with  the  hand  on 
the  abdomen.  In  one  case  we  could  easily  grasp  the  stones  (there  were  two) 
with  the  hand  through  the  soft,  flaccid,  abdominal  walls. 

Vesical  calculus  is  occasionally  found  in  female  children  :  in  such  cases 
the  urethra  should  be  rapidly  dilated  with  a  three-bladed  dilator  or  a  pair 
of  dressing  forceps,  and  the  stone  extracted.  If  the  calculus  is  large,  it 
should  be  crushed  before  extraction  and  the  bladder  Avell  washed  out.  Rapid 
dilatation  is  not,  as  a  rule,  followed  by  incontinence,  even  temporarily  ;  in  a 
case  of  our  own  the  urethra  of  a  child  three  years  old  was  dilated  sufficiently 
to  admit  the  little  finger,  and  there  was  no  incontinence,  even  immediately 
after  the  operation. 


Cystitis  613 

The  mortality  after  lithotomy  in  children  is  usually  about  5  per  cent. 
Death  when  it  occurs  is  due  either  to  exhaustion  of  the  child  by  distress  and 
pain  before  the  operation,  to  kidney  disease,  or  in  some  cases  to  peritonitis, 
cellulitis,  septicaemia,  or  hitmorrhage. 

Cystitis. — Though  cystitis  in  children  is  very  commonly  due  to  stone,  it 
is  by  no  means  rare  to  find  other  causes  for  it  ;  thus  retention  from  phimosis, 
or  a  contracted  meatus,  or  possibly  a  growth,  may  give  rise  to  it  :  tubercu- 
losis of  the  bladder  often  is  a  cause  of  severe  cystitis  with  much  pain  and 
hiematuria,  while  frequent  micturition  with  phosphatic  deposit  often  occurs  in 
children  from  such  causes  as  errors  of  diet,  or  from  no  obvious  reason.  Rectal 
irritation  may  give  rise  to  frequent  micturition  and  even  to  htematuria. 

The  so-called  '  irritable  rugous  bladder'  is  a  condition  often  described  as 
a  disease  ;  there  is  no  doubt  that  certain  children  are  brought  with  symptoms 
pointing  to  stone,  and  on  soundmg  them  no  stone  is  found,  Ijut  the  bladder 
feels  rough  and  traversed  by  ridges.  We  are,  however,  inclined  to  think 
this  is  not  a  pathological  condition  in  itself,  but  simply  the  result  of  some 
passing  irritation  such  as  hyperacid  or  phosphatic  urine,  since  these  cases 
seldom  require  prolonged  treatment  and  usually  rapidly  lose  their  symptoms 
after  a  course  of  salines  followed  by  tonics.  In  Mr.  Holmes's  view  it  is 
simply  a  contracted  bladder  resulting  from  some  irritation.  Renal  calculus 
and  phimosis  sometimes  are  the  cause  of  this  condition. 

Tumours  of  the  bladder  are  rare  in  children  ;  one  case  of  prostatic  tumour 
has  been  already  mentioned,  and  Owen  records  a  case  of  his  own,  and 
mentions  Giraldes'  and  Birkett's  cases.  Shattock  has  also  recorded  a  case 
of  mucous  polypus  in  the  'British  Medical  Journal,'  1883,  page  15,  and 
several  cases  of  sarcoma  have  also  been  met  with  {vide  Southam)  ;  indeed 
sarcoma  of  the  bladder  occurs  more  frequently  in  childhood  than  any  other 
form  of  growth. 

Tuberculous  cystitis  may  be  recognised,  in  the  absence  of  stone  or  other 
obvious  cause,  by  pain  in  urination,  itching  at  the  end  of  the  penis,  pain  in 
the  hypogaStrium  and  perinaeum,  frequent  micturition,  and  sometimes  incon- 
tinence. The  pain  may  be  greatly  lessened  by  passing  urine  as  soon  as  the 
least  inclination  to  do  so  is  felt  ;  the  urine  is  alkaline,  with  a  deposit  of  pus 
and  stringy  mucus  and  epithelium  ;  sometimes  there  is  haematuria,  and  the 
bladder  usually  very  readily  bleeds — for  instance,  after  gentle  sounding.  We 
have  found  a  chain  of  enlarged  lymphatics  on  rectal  examination  in  a  case 
of  this  sort,  and  also  swelling,  probably  glandular,  in  the  iliac  fossa.  Pres- 
sure over  the  bladder  sometimes  relieves  pain.  We  have  not  found  tuber- 
culous cystitis  in  children  associated  with  genito-urinary  tuberculosis,  as  is  so 
commonly  the  case  in  adults,  but  the  disease  is  not  common  enough  to  speak 
with  authority.  Terrillon  says  the  deposit  is  less  gelatinous  and  more  floc- 
culent,  and  the  pain  more  constant  in  tuberculous  than  in  simple  cystitis, 
while  bleeding  is  an  early  symptom.  Where  the  bladder  alone  is  involved 
no  casts  will  be  found  in  the  urine  ;  their  presence  would  of  course  point  to 
renal  mischief.  Ulceration  takes  place  after  a  time,  and  the  ulcers  may  be 
single  and  small,  or  numerous  and  large  ;  they  are  usually  at  the  trigone. 

Treatment. — Alkalies,  citrate  of  potash,  and  boric  acid  are  the  remedies 
most  useful  as  given  internally,  opium  and  henbane  being  added  where 
much  pain  is  present.     Washing  out  the  bladder  with  boric  acid  (gr.  x  to 


6 14  Diseases  of  the  Genito-urinary  System 

5  i)  is  of  much  value  in  simple,  but  sometimes  too  painful  in  tuberculous 
cystitis.  Powdered  iodoform  washed  into  the  bladder  forms  a  coating  upon 
its  surface,  and  gives  much  relief  in  some  cases  ;  it  appears,  however,  to  be 
somewhat  specially  prone  to  cause  iodoform  poisoning  :  this  method  was, 
we  believe,  first  used  by  Mr.  Whitehead  for  malignant  disease.  Rawdon 
suggests  cystotomy  in  cases  of  tuberculosis  where  the  symptoms  are  intract- 
able, and  suprapubic  cystotomy  with  subsequent  scraping  of  the  ulcer  has 
been  done  in  some  instances. 

Incontinence  of  Urine. — During  the  first  few  months  of  life  the  infant 
has  no  voluntary  control  over  the  sphincters  of  the  bladder  ;  urination  at  this 
time  is  a  reflex  act,  like  the  respiratory  movements  or  deglutition.  During  the 
last  few  months  of  the  first  year,  a  good  nurse  will  have  trained  the  infant  to 
retain  its  urine  till  held  over  the  chamber  vessel,  so  that  by  the  end  of  the 
first  year  the  napkin  can  be  dispensed  with  during  the  daytime.  Before 
the  end  of  the  second  year  accidents  either  by  night  or  day  ought  to  be 
infrequent.  Unduly  frequent  micturition  may  be  due  to  mere  habit,  to  a 
too  often  occurring  desire  to  pass  urine,  or  to  an  absolute  inabihty  to  retain 
it.  In  the  former  the  apparatus  is  perfect,  but  is  by  some  cause  or  other  too 
often  excited  ;  in  the  last  there  is  either  paralysis  or  a  malformation. 
Nocturnal  incontinence  belongs  to  the  former  group  ;  diurnal  or  continuous 
incontinence  may  be  due  to  either  condition.  Thus  a  child  may  have  a 
frequent  desire  to  pass  water  because  a  larger  amount  is  secreted,  as  in 
diabetes  insipidus  ;  because  it  has  a  congenitally  small  bladder ;  because  it 
has  a  stone  or  hyperacid  urine,  or  cystitis,  or  a  feeling  of  irritation  about  the 
penis  from  an  adherent  or  tight  prepuce  or  a  contracted  meatus  ;  or  because 
worms  or  other  rectal  irritation  are  present.  In  all  these  conditions,  except 
that  of  too  small  a  bladder,  the  urinary  apparatus  may  be  quite  perfect, 
but  it  is  irritated. 

On  the  other  hand,  there  may  be  continuous  dribbling  of  urine  from  the 
bladder,  as  a  result  of  distension  and  overflow  from  obstruction  ;  or  in  case 
of  entire  absence  of  the  bladder,  or  extroversion,  or  imperfect  development 
of  the  neck  of  the  bladder  or  of  the  urethral  muscles  ;  or,  again,  from 
deficient  innervation,  as  in  paraplegia,  or  from  imperfection  of  the  micturition 
centre  in  the  spinal  cord,  as  seen  in  some  cases  of  spina  bifida.  Mention 
must  also  be  made  of  certain  rare  conditions,  such  as  an  abnormal  communica- 
tion between  the  bladder  or  ureters  and  the  exterior.  Obviously  a  child 
that  can  hold  its  water  during  the  day  can  have  none  of  these  conditions  ; 
hence,  when  a  child  is  brought  and  said  to  be  unable  to  hold  its  water,  the 
first  question  is  whether  the  condition  is  nocturnal  only  or  constant. 
Dribbling  from  over-distension  due  to  obstruction  is  nearly  always  the 
result  of  either  an  impacted  urethral  calculus  or  of  phimosis,  less  often  of  a 
contracted  meatus,  though,  of  course,  in  these  there  is,  as  a  rule,  complete, 
or  almost  complete,  retention  rather  than  overflow. 

Inability  to  retain  the  urine  is  occasionally  seen  associated  with  hypo- 
spadias and  incontinence  of  faeces  :  in  such  cases  the  condition  is  no  doubt 
due  to  actual  malformation  of  the  sphincters. 

Dribbling  from  paraplegia  will  be  recognised  by  the  associated  paralyses  ; 
so  too  with  the  case  of  spina  bifida  :  hence  examination  of  the  spine  should 
be  made  in    all  cases,  and  the  child's  cerebral    condition  should  also  be 


Incontinence  of  Urine  6 1  5 

inquired  into.  A  careful  examination  as  to  the  condition  of  the  bladder  and 
urethra  should  be  made,  to  see  if  there  is  any  deficiency  or  abnormal 
"arrangement  of  these  parts  ;  the  urine  should  be  examined  for  excess  of  uric 
acid,  also  for  albumen  and  sugar. 

Diurnal  incontinence  is  much  less  common  than  nocturnal,  thuugli 
frequent  micturition  without  any  actual  inability  to  retain  urine  is  common 
enough  ;  in  such  cases  the  sources  of  irritation  already  mentioned  should 
be  sought  for  and  removed.  Sometimes  a  child,  the  subject  of  nocturnal 
incontinence,  passes  urine  frequently  by  day,  but  is  able  to  retain  it. 

Ordinary  nocturnal  incontinence  (or  enuresis,  as  it  is  sometimes  called) 
is  more  common  in  boys  than  in  girls  ;  it  may  occur  at  any  age  before 
puberty,  but  very  rarely  persists  beyond  that  time ;  if  it  does  so  it  is  usually 
incurable,  and  this  rare  condition  is  said  to  be  most  often  met  with  in  girls. 

The  discharge  of  urine  may  take  place  once  or  several  times  during  the 
night ;  perhaps  most  often  during  the  first  sound  sleep,  and  again  in  the 
early  morning. 

In  cases  of  nocturnal  incontinence  those  conditions  which  have  been 
mentioned  as  giving  rise  to  a  frequent  desire  to  pass  urine  during  the  day 
should  be  looked  for,  since,  when  the  child  is  awake,  he  may  be  able  to 
control  the  flow,  or  pass  his  urine  in  a  suitable  place  ;  while  during  sleep  no 
such  power  is  exerted.  Other  causes,  such  as  unduly  deep  sleep,  due  in  some 
cases  to  the  semiasphyxiated  condition  caused  by  enlarged  tonsils  or  post- 
nasal adenoids,'  dreams  in  which  the  child  imagines  that  it  is  properly 
passing  its  water,  gastric  disturbance  from  late  or  unwholesome  meals, 
temporary  polyuria  from  free  drinking  of  fluids  at  night,  and  perhaps  mas- 
turbation, may  be  added  to  the  list.  We  have  also  reason  to  think  that  mere 
delicacy  of  health,  often  conjoined  with  a  somewhat  unstable  and  easily 
excited  mind,  such  as  is  sometimes  seen  in  children  born  or  brought  up  in 
hot  climates,  may  give  rise  to  enuresis.  I'ossibly  in  some  cases  renal  calculus 
or  pyelitis  of  tubercular  origin  may  give  rise  to  incontinence. 

Treat»ie7it. — Setting  aside  the  irremediable  malformations  and  the  cases 
due  to  paraplegia,  the  first  thing  is  to  look  for  and  remove  any  of  the  sources 
of  irritation.  If  there  is  phimosis,  circumcision  or  the  breaking  down  of 
adhesions  ;  if  there  is  a  small  meatus,  enlargement  by  incision  will  be  re- 
quired. The  bladder  should,  of  course,  also  be  sounded  in  any  case  of  doubt, 
or  if  the  condition  does  not  speedily  yield  to  medicinal  treatment.  If  the 
urine  is  hyper-acid  or  contains  crystals  of  uric  acid,  or  there  is  evidence  of 
cystitis,  citrate  of  potash  or  liquor  potassa;  should  be  given  ;  the  child  should 
be  carefully  dieted  and  its  allowance  of  meat  curtailed,  while  any  irritating 
vegetable  food,  such  as  rhubarb,  should  be  forbidden.  Late  meals  should 
not  be  allowed,  nor  should  the  child  take  any  fluid  for  an  hour  or  two 
before  going  to  bed.  Too  great  a  weight  of  bed-clothes  and  the  habit  of 
sleeping  upon   the  back  should  be  avoided  ;    in  the  latter,  the  immediate 

1  Dr.  L.  Freyberger  found  on  inquiry  that  in  350  cases  of  enlarged  tonsils,  there  was 
enuresis  in  104  ;  but  193  of  these  were  complicated  with  other  troubles,  such  as  phimosis, 
worms,  indigestion,  &c.  Of  the  uncomplicated  cases  (157),  only  26  had  enuresis,  while  in 
the  other  class  (193),  78  had  enuresis.  He  comes  to  the  conclusion  that  in  uncomplicated 
cases  of  enlarged  tonsils  only  some  16  per  cent,  will  have  nocturnal  incontinence  ;  while  in 
the  complicated  cases  about  40  per  cent.     It  is  obvious  that  the  inquiry  is  a  difficult  one. 


6i6  Diseases  of  the  Genito-iirinary  System 

impact  of  the  urine  upon  the  trigone  is  believed  to  excite  the  efifort  to  empty 
the  viscus. 

For  nocturnal  incontinence  alone  the  most  successful  drug  is  undoubtedly 
belladonna,  or,  still  better  in  some  cases,  atropia.  Belladonna  should  be 
given  in  full  and  increasing  doses  :  for  a  child  two  years  old  it  is  well  to 
begin  with  five  or  ten  drops  of  tincture  three  times  daily,  and  mcrease  the  dose 
by  five  drops  every  twelve  hours  till  the  physiological  effects  are  produced, 
bearing  in  mind  that  children  are  not  readily  susceptible  to  the  action  of  the 
drug  ;  as  soon  as  this  point  is  reached  the  dose  should  be  continued  for 
several  days.  If  the  treatment  is  successful,  it  should  be  continued  for  a 
week,  and  then  the  dose  gradually  diminished,  increasing  it  again  if  there 
is  any  relapse.  We  have  seen  liquor  atropiae  given  at  night  in  2-minim 
doses,  reached  gradually,  cure  a  child  two  years  old  in  which  belladonna 
had  failed.  The  drug  probably  acts  both  by  stimulating  the  contraction 
of  the  sphincter  muscles  and  by  acting  as  a  sedative.  Bromide  of  potassium, 
alone  or  with  belladonna,  ergot,  cantharides,  nitrate  of  potash,  camphor, 
and  other  drugs,  has  been  employed.  Strychnine  is  chiefly  of  use  in 
diurnal  incontinence,  though  sometimes  it  succeeds  in  the  nocturnal  form  ; 
it  is  said  by  Bouchut  to  be  a  dangerous  drug  for  children.  Such  treatment 
as  blistering,  or  painting  over  the  orifice  of  the  urethra  with  nitrate  of  silver, 
or  the  use  of  a  perinatal  truss,  is  not  to  be  recommended.  The  child  should 
be  made  to  pass  water  just  before  going  to  bed,  and  should  be  taken  up  again 
in  an  hour's  time,  and  if  possible  once  again  during  the  night  ;  he  should  be 
encouraged  to  try  to  control  the  inclination  and  to  exert  his  will,  but  on 
no  account  should  he  be  threatened  or  punished,  except  possibly  in  the 
exceptional  cases  when,  as  sometimes  happens,  the  presence  of  one  child 
with  incontinence  in  a  school  induces  an  epidemic,  as  it  were,  among  the 
others  ;  in  such  instances  probably  the  affection  is  in  the  acquired  cases 
simply  a  trick,  and  maybe  controlled  by  fear  of  punishment.  The  disastrous 
results  of  frightening  such  children  into  tying  strings  round  the  penis,  as  well 
as  the  misery  inflicted  by  the  shame  of  believing  that  what  is  really  a  disease 
is  a  fault,  are  sufficient  arguments  against  such  cruelty.  Cold  sponging  to 
the  perineeum  is  sometimes  useful,  and  we  have  known  the  use  of  the  constant 
current,  one  pole  being  appHed  above  the  pubes  and  the  other  in  the 
perinseum  or  over  the  sacrum,  to  succeed  where  other  means  have  failed  ; 
the  interrupted  current  also  sometimes  answers.  The  application  of  nitrate 
of  silver  to  the  neck  of  the  bladder  is  advocated  by  Holmes.  In  weakly 
children  and  in  cases  of  diurnal  incontinence,  when  no  organic  cause  can  be 
found,  tonics,  iron,  strychnine,  good  food,  and  sea  air  will  often  prove 
successful,  and  we  have  known  sea  air  cure  enuresis.  The  possible  existence 
of  chronic  renal  disease  or  diabetes  must  be  borne  in  mind. 

In  inveterate  cases  in  girls  dilatation  of  the  urethra  and  exploration  of 
the  bladder  may,  as  pointed  out  by  Owen,  cure  the  affection  even  if  no 
organic  disease  is  found. 

Retention  of  Urine. — The  causes  leading  to  retention  of  urine  are 
mentioned  under  their  several  headings,  but  it  may  be  convenient  here  to 
group  them  together.  They  are  congenital  malformations,  impacted  calculus, 
phimosis,  ruptured  or  strictured  urethra,  including  stricture  of  the  meatus, 
pressure  on  the  urethra  by  abscess  or  a  new  growth,  blocking  of  the  orifice 


Retention  of  Urine — Extroversion  of  Jlladder  617 

of  the  urethra  by  a  vesical  or  prostatic  tumour,  or,  lastly,  the  tying  of  a  string 
round  the  penis.  It  must  be  remembered  that  retention  of  urine  may  be 
\oIuntary,  or  imaginary  on  the  part  of  the  friends  :  voluntary  where  the 
passage  of  the  water  causes  pain,  as  is  often  seen  after  circumcision, 
when  the  urine  flowing  over  the  surface  causes  discomfort.  We  have  never 
seen  any  harm  other  than  alarm  to  the  friends  result  from  this  voluntary 
retention,  though  it  is  well  in  such  cases,  if  a  warm  bath  does  not  relieve 
the  retention,  to  pass  a  catheter  into  the  bladder.  Lastly,  retention  must  not  be 
confounded  with  suppression  of  urine  from  any  cause.  Of  course,  retention  of 
urine  if  unrelieved  will  lead  to  extravasation,  the  treatment  of  which  is  free 
incision  deeply  into  all  the  infiltrated  tissues,  so  that  a  free  outlet  for  the  urine 
already  extravasated  is  provided,  as  well  as  any  further  mischief  prevented. 

IMCalformation  of  the  Genlto-urinary  Org'ans.  Extroversion  of  the 
Bladder. —  Deficient  closure  of  the  ventral  lamina;,  giving  rise  to  hiatus  of 
the  abdominal  wall,  has  already  been  mentioned  in  connection  with  umbilical 
hernia  (p.  156).  In  certain,  not  rare,  instances,  however,  the  lower  part  of 
the  abdommal  wall,  from  the  umbilicus  or  its  neighbourhood  downwards, 
may  fail  to  close,  and  coupled  with  this  there  may  be  deficiency  of  the 
anterior  wall  of  the  bladder,  constituting  the  condition  known  as  extroversion 
or  exstrophy  of  the  bladder,  ectopia  vesicas,  or  hiatus  of  the  bladder.  A 
patent  urachus  or  even  a  protrusion  of  the  bladder  wall  through  such  a  passage 
may  also  be  found  ;  vide  Tanner,  '  Diseases  of  Childhood.'  In  this  condition 
the  lower  part  of  the  abdomen  presents  a  red  rugous  area  covered  with 
mucous  membrane,  which  is  usually  excoriated  from  friction  and  irritation, 
often  more  or  less  coated  with  mucus  and  phosphates.  From  this  surface, 
or  rather  from  the  orifices  of  the  ureters  exposed  upon  it,  the  urine  continu- 
ously dribbles,  keeping  the  child  always  wet,  and  leading  to  irritation  of  the 
neighbouring  skin.  This  red  mucous  surface  is  the  posterior  wall  of  the 
bladder,  which  is  usually  flush  with  the  abdominal  wall  ;  hence  in  most 
cases  there  is  no  bladder  cavity,  though  occasionally  there  is  a  sHght  depres- 
sion. More  often  the  surface  is  corrugated  and  somewhat  protuberant,  and 
on  drawing  down  the  penis,  which  is  always  distorted  and  ill  developed  {vide 
Epispadias),  the  orifices  of  the  ureters  can  be  seen,  and  drops  of  urine  may 
be  watched  flowing  from  them,  and  often  escaping  in  a  htde  jet  when  the 
child  cries  or  strains.     The  malformation  is  most  common  in  males. 

On  further  examining  such  a  child,  it  will  usually  be  found  that  the 
symphysis  pubis  is  deficient,  the  two  bones  faihng  to  meet  in  the  middle  line, 
and  being  only  connected  by  fibrous  tissue.  The  umbilicus  may  be  absent 
altogether,  or  may  be  more  or  less  well  formed.  The  scrotum  is  always 
imperfectly  developed,  and  the  testes  do  not  fully  descend,  usually  lying  in, 
or  just  outside,  the  inguinal  canals.  Very  commonly  there  are  inguinal 
hernias  developed,  and  these  may  even  become  strangulated.  We  have  had 
occasion  to  operate  in  such  a  case.^ 

1  According  to  Dr.  Champneys,  St.  Bartholomew  s  Hospital  Reports,  1877,  extrover- 
sion may  be  associated  with  talipes  and  other  deformities  ;  the  sex  may  be  doubtful  from 
e.xternal  appearances  ;  there  may  be  rectal  prolapse,  with  a  long,  loose,  rectal  mesentery. 
All  grades  of  deformities,  from  mere  separation  of  the  symphysis  pubis,  with  perhaps  a 
hernial  pouch,  but  no  deficiency  of  the  bladder,  may  be  met  with  ;  in  the  second  degree  of 
deformity  there  may  be  prolapse  of  the  bladder,  though  it  is  itself  perfect  ;  the  prolapse 


6i8  Diseases  of  the  Geiiito-iirmary  System 

This  deformity,  which  is  quite  unmistakable,  gives  rise  to  much  trouble, 
both  from  the  constant  wetting  and  excoriations  as  well  as  from  the  in- 
capacities associated  with  it.  It  is  impossible  in  most  cases  to  fit  any 
apparatus  satisfactorily  to  receive  the  urine.  Hence  the  treatment  is  solely 
operative  ;  and  even  this,  it  must  be  confessed,  is  not  always  satisfactory. 
Attempts  have  been  made  to  divert  the  ureters  into  the  intestine,  but  not 
hitherto  with  success  (T.  Smith  and  Simon).  Holmes,'  Ayres,  Wood,  Greig 
Smith,  and  others  have  devised  operations  for  covering  in  the  exposed 
bladder ;  these  consist  of  dissecting  up  a  flap  from  the  abdominal  wall  or 
scrotum,  and  turning  it  over  the  bladder  surface,  subsequently  covering  over 
the  raw  side  of  the  flap  with  other  superimposed  flaps  from  the  groins.  For 
details  of  the  operation  we  must  refer  to  works  on  operative  surgery.  Several 
successive  attempts  are  often  required  before  a  good  result  is  obtained,  and 
there  is  sometimes  a  tendency  for  the  flaps  to  retract  and  leave  the  lower 
part  of  the  bladder  exposed  ;  this  difficulty  is  met  by  subsequent  attachment 
of  the  flaps  to  the  scrotum  or  labium  below,  a  plan  suggested  by  Mayo 
Robson,^  and  one  we  have  found  of  value.  On  the  whole,  the  result  of  our 
experience  is  that  the  operation  should  certainly  be  done  in  all  cases  where 
the  child  is  in  a  condition  to  bear  a  somewhat  severe  and  prolonged  manipu- 
lation, and  that  a  great  improvement  may  be  expected  as  a  final  result  (fig. 
135).  The  child  should  not  be  operated  on  until  it  is  three  or  four  years 
old.  It  has  been  proposed  to  scrape  or  cut  away  the  mucous  surface  of  the 
bladder  except  at  the  orifices  of  the  ureters,  and  thus  avoid  irritation  of  an 
exposed  mucous  membrane  ;  we  are  trying  this  method  now.-  After  opera- 
may  take  place  through  the  urethra  or  urachus  (Vrolik,  Froriep) ;  the  third  degree  is  the 
ordinar}'  form  ;  while  in  the  fourth  and  most  severe  degree  there  is  extroversion  and  divi- 
sion of  the  bladder  into  two  halves  b}'  the  opening  of  the  intestine  between  them.  The 
condition  really  arises  from  the  fact  that  the  allantois  is  developed  by  two  lateral  portions 
which  afterwards  meet  in  the  middle  line,  and  thus  the  various  degrees  of  deformity  of  the 
bladder,  epispadias  &c.  are  explained  [vide  Baly  in  Miiller's  Physiology).  Union  between 
the  halves  of  the  allantois  takes  place  at  the  third  week  of  foetal  life,  so  the  deformity  must 
exist  at  that  time. 

The  condition  of  the  umbilical  vessels  is  inconstant  :  they  may  run  separately  to  the 
placenta  (Dietrich).  The  umbilicus  is  lower  than  usual,  and  the  anus  is  generally  more 
anterior  than  usual.  Hernia  are  inconstant.  The  external  genitals  may  be  deficient 
altogether  or  developed  in  varying  degrees  ;  the  testes  may  be  retained,  or  may  descend 
into  the  scrotum  and  be  well  developed.  The  symphysis  is  not  always  ununited  ;  when  it 
is  so  it  causes  awkwardness  of  gait. 

As  Tenon  pointed  out,  the  malformation  is  not  a  cleft  of  the  bladder  merely,  since 
there  is  a  deficiency  of  all  excepting  the  trigone  and  neighbouring  parts.  The  pelvis  of 
the  kidney  and  the  ureters  are  usually  dilated,  and  may  open  into  the  rectum,  vagina,  or 
urethra. 

The  intestine  is  variously  malformed  or  deficient,  and  there  maybe  imperforate  or  mis- 
placed rectum. 

For  further  details  and  references  Dr.  Champneys'  able  paper  should  be  looked  at ; 
from  it  much  of  the  above  is  taken. 

1  Brii.  Med.  Jour.  January,  31,  1885. 

2  Excision  of  the  bladder,  with  or  without  transplantation  of  the  ureters,  direct  suture 
of  the  vesical  margins,  with  or  without  section  of  the  sacro-iliac  joints,  to  allow  approxima- 
tion of  the  rami  of  the  pubes  have  also  been  suggested  ;  but  no  sufficiently  encouraging 
results  from  these  methods,  except  in  one  case  of  Wyman's,  have  been  obtained.  A  good 
summar}'  of  the  various  operations  will  be  found  in  Aim.  des  Mai.  des  Organes  Giiiito- 
nrinaires,  March  1888,  by  Pousson. 


Extrovcrsio7t  of  lUadder 


bi9 


tion  one  of  the  troubles  is  the  constant  formation  of  phosphatic  deposit 
about  the  parts  ;  careful  cleansing  and  daily  syringing  with  a  dilute  acid 
solution  is  required.  We  have  found  hydrochloric  acid  \\  xx,  glycerine  5  i) 
water  5  i,  a  useful  form  of  wash.  If,  however,  as  is  sometimes  the  case,  the 
deposit  persists  in  spite  of  these  measures,  we  have  found  that  scraping  it 
away  from  time  to  time  with  a  sharp  spoon  is  the  most  effectual  means  of 


Fig.  135. — Shows  the  resuh  of  a  plastic  operation  for  Extroversion  of  the  Bladder  in  a  boy 
A  urinal  can  be  worn  over  the  orifice  now  remaining.     A  points  to  the  glans  penis. 


getting  rid  of  it.     When  the  bladder  surface  has  been  covered  in  as  shown 
in  the  figure,  an  appliance  is  readily  adapted  to  receive  the  urine. 

In  extroversion  of  the  bladder  in  the  male  the  penis  is  nearly  always 
deformed,  the  corpora  cavernosa  are  deficient  to  a  greater  or  less  degree,  and 
the  corpus  spongiosum  is  ununited  on  its  upper  surface,  so  that  the  floor  of  the 
urethra  is  exposed  on  the  dorsum  of  the  penis.  The  whole  organ  is  stunted 
and  turned  up  against  the  abdomen  ;  the  prepuce  is  usually  redundant  below, 
and  the  glans  is  generally  better  developed  than  the  rest  of  the  penis. 


620  Diseases  of  the  Genito-urinary  System 

Epispadias. — The  condition  of  penis  above  described  may  occur  without 
extroversion,  constituting  epispadias.'  In  such  cases  there  is  usually  imper- 
fect power  of  retention  of  urine  from  deficient  muscular  development  at  the 
neck  of  the  bladder,  and  for  sexual  functions  the  organ  is  useless.  In  such 
cases  an  apparatus  is  readily  applied  to  prevent  the  discomfort  of  constant 
wetting  ;  but  to  improve  the  power  of  urination,  and  perhaps  the  sexual 
function,  operations  may  be  performed,  consisting  in  either  turning  down  a 
hood-like  flap  from  the  front  of  the  abdominal  wall  over  the  urethral  groove, 
or  in  dissecting  up  flaps  of  skin  and  bringing  them  over  the  dorsum — or, 
lastly,  in  taking  a  flap  from  the  scrotum  and  turning  it  upwards  over  the 
penis,  which  is  passed  through  a  slit  in  the  centre  of  the  flap.  Any  small 
fistulous  openings  left  after  union  of  the  main  flaps  are  closed  by  subsequent 
operation  or  by  repeated  application  of  the  actual  cautery.  In  all  such 
operations  it  is  a  good  plan,  as  a  preliminary  step,  to  open  the  urethra  or 
bladder  through  the  perineum,  so  as  to  allow  the  urine  to  drain  away  freely, 
without  flowing  over  the  wound.  Our  colleague,  Mr.  Hardie,  and  Mr. 
Howlett,  of  Hull,  have  adopted  this  plan  with  good  results. 

Hypospadias. — When  the  floor  of  the  urethra,  together  with  the  corpus 
spongiosum,  is  deficient  to  a  greater  or  less  degree,  the  deformity  known  as 
hypospadias  is  present.  In  the  slighter  cases  the  deformity  is  merely  one 
of  the  urethral  orifice,  which  opens  on  the  under  surface  of  the  glans  penis 
instead  of  upon  its  apex,  though  even  in  these  cases  the  corpus  spongiosum 
is  always  thinner  and  less  developed  than  it  should  be.  A  dimple  usually 
represents  the  opening  of  the  urethra,  or  a  groove  may  run  on  from  the 
existing  opening  to  the  end  of  the  glans.  All  degrees  of  malformation  are 
met  with  from  this  to  cases  where  the  urethra  opens  in  the  perinseum,  behind 
the  scrotum.  In  severe  cases,  the  corpus  spongiosum  being  entirely  deficient 
below,  the  penis  is  bent  downwards  and  held  down  by  fibrous  bands  repre- 
senting the  aborted  spongy  body  ;  it  is  also  bound  down  by  the  deficiency  of 
the  prepuce  below,  though  a  redundant,  hood-like  fold  overlies  the  glans 
above.  In  the  severest  cases  the  scrotum  is  cleft  and  ill  developed,  and  the 
testes  are  retained  or  imperfectly  descended,  and  the  arrest  of  development 
may  be  such  as  to  give  rise  to  doubts  as  to  the  sex  of  the  individual  ;  such 
are  the  majority  of  the  so-called  hermaphrodites.'- 

The  slighter  degrees  of  deformity,  where  the  urethra  opens  at  the  base  of 
the  glans,  need  no  treatment,  and  do  not  interfere  with  either  the  urinary  or 
sexual  functions  as  a  rule,  though  we  have  met  with  a  case  where  this 
condition  was  associated  with  incontinence  of  urine  and  fasces,  probably 
due  to  deficient  development  of  the  sphincters  of  both  outlets.  In  all  cases 
of  hypospadias  a  probe  passed  into  the  urethra  will  show  how  thin  the 
lower  wall  is,  and  the  meatus  is  often  contracted  and  insufficient.  Sometimes 
the  opening  is  sufficiently  far  forwards  to  serve  all  purposes,  but  the  penis  is 
tightly  bound  down  to  the  front  of  the  scrotum.  In  such  cases  the  organ 
may  be  liberated  by  careful  dissection,  but  unless  great  caution  is  observed 

'  A  case  of  epispadias  in  a  girl  is  recorded  by  Smith  in  Brit.  Med.  Joiw.  September  20, 
1884. 

^  Sometimes  the  urethra  is  continued  on  to  the  glans,  but  there  is  a  congenital  urethral 
fistula  further  back,  even  within  the  rectum,  and  urine  escapes  by  both  orifices.  For 
details  of  the  various  forms  of  hypospadias  vide  Med.  Chron.  December  1894. 


Hypospadias  62 1 

the  thin  floor  of  the  urethra  will  be  cut  through,  and  a  urinary  fistula  result. 
Where  the  opening  is  further  back  than  half  the  length  of  the  penis  an 
operation  may  be  performed  to  lengthen  the  channel  ;  with  or  without  a 
preliminary  cystotomy  or  urethrotomy,  flaps  should-be  dissected  up  from  the 
sides  of  the  penis  and  turned  over  one  another  (method  of  superimposed 
flaps).  This  is  a  successful  plan,  but  even  it  often  fails  from  non-union,  or 
breaking  down  again  after  partial  adhesions.  We  more  often  perforate  the 
prepuce  and  bring  up  the  glans  through  it,  and  then,  after  refreshing  the 
edges  of  the  preputial  fold  and  of  the  urethral  furrow,  unite  them,  completing 
the  new  floor  of  the  urethra  by  subsequent  operations. 

V  Congenital  Contraction  of  tbe  IVXeatus  17rinarius  and  Congenital 
Stricture  of  the  ITrethra  have  already  been  mentioned.  We  have  met  with 
two  instances  of  the  latter  :  one,  seen  in  adult  life,  was  remedied  by  catheterism 
in  the  ordinary  way  ;  in  the  other,  an  infant,  there  was  retention  of  urine, 
with  overflow.  On  passing  a  cathetertwo  distinct  obstructions  were  found,  one 
at  the  front  of  the  scrotum,  and  the  other  in  the  prostatic  region  ;  they  appeared 
to  be  definite  bars  of  thickened  tissue,  the  latter  closely  simulating  prostatic 
enlargement,  which,  if  it  existed,  only  affected  the  middle  lobe.^ 

Congenital  contraction  of  the  meatus  may  become  an  important  afifection, 
giving  rise  to  incontinence,  to  retention  and  consequent  cystitis,  and  indeed 
to  all  the  secondary  troubles  associated  with  obstruction  to  the  urinary  out- 
flow. In  one  instance  a  boy  of  five  years  old  was  brought  to  us,  who  was 
said  to  have  had  gonorrhoea  for  three  years,  and  was  believed  to  have  been  tam- 
pered with  ;  there  was  a  distinct  gleety  discharge,  and  the  meatus  was  very 
small.  All  the  symptoms  disappeared  after  slitting  the  meatus  and  passing  a 
catheter  a  short  distance  down  the  urethra  at  frequent  intervals  for  a  few  weeks  ; 
the  child  was  subsequently  neglected,  and  re-contraction  took  place.  The 
following  case  further  illustrates  the  evils  of  a  narrow  meatus  : 

Contracted  Meatus  Urinarius.  Retention. — J  as.  F. ,  age  4  years  ;  admitted  December  7, 
1882.  Well  till  five  weeks  before  admission,  when  he  was  unable  to  pass  urine  without 
pain  ;  subse^quently  had  pain  in  hypogastrium  and  became  ill  in  himself ;  never  passed 
blood  :  was  catheterised  at  the  out-patient  room  twice,  and  once  passed  urine  voluntarily. 
On  admission  was  found  to  have  a  contracted  meatus,  and  was  catheterised,  a  small 
instrument  (size  not  recorded)  being  passed  ;  urine  clear,  sp.  gr.  1028,  faintly  acid,  slight 
sediment  of  mucus  and  phosphates  on  standing,  no  albumen  ;  the  edges  of  the  meatus 
were  found  to  become  glued  together,  and  he  was  unable,  even  by  violent  straining,  to  pass 
urine  himself;  the  bladder  contracted  tightly  round  the  catheter.  December  11,  the 
meatus  was  incised  to  enlarge  the  orifice,  and  a  No.  8  silver  catheter  passed  dail}'  through 
the  meatus,  but  not  into  the  bladder.  He  was  discharged  on  the  17th  with  all  his  sym- 
ptoms relieved.  It  is  usually  said  that  retention  in  children  is  always  due  either  to  impacted 
calculus  or  extreme  phimosis.  Here  probably  some  balanitis  led  to  ulceration  and  cica- 
tricial contraction  of  the  meatus,  the  edges  of  which  were  probably  acting  as  valves,  which 
shut  by  the  pressure  of  the  urine. 

Complete  obliteration  of  the  urethra  may  also  be  met  with,  as  in  a  case 
recorded  by  Partridge  and  Watson.-  Mr.  Gray  and  others  have  recorded  cases 

1  Dr.  Mudd,  St.  Louis  Med.  and  Surg.  Jour.  November  1883,  mentions  a  case  of 
enlargement  of  the  middle  lobe  in  a  child  of  thirteen  months  ;  the  swelling  proved  to  be  a 
myoma. 

-  Path.  Soc.  Trans,  vol.  xiv.  The  ureters  were  enormously  dilated  ;  one  kidney  was 
atrophied,  and  the  colon  ended  in  the  bladder  ;   other  deformities  also  existed.     Another 


622  Diseases  of  the  Genito-urinary  System 

of  double  urethra  one  on  the  dorsum  and  the  other  in  the  normal  position, 
both  communicating  with  the  bladder,  though  not  with  each  other.  ^ 

Prolapse  of  the  mucous  membrane  of  the  urethra  in  girls  may  be  caused 
by  straining  ;  it  gives  rise  to  pain,  bleeding,  and  irritability  of  the  bladder. 
Day,  who  describes  the  condition  in  the  '  Medical  News,'  Dec.  1883,  advises 
astringents  in  mild  cases,  and  removal  by  ligature  of  the  prolapsed  part  in  more 
severe  instances.  Dr.  Coley  removed  the  prolapse  by  radial  incisions  and  ob- 
tained a  good  result  {vide  '  Brit.  Med.  Jour.'  November  i,  1890,  also  April  12, 
1890).  We  have  met  with  a  case  of  this  condition  in  which  the  prolapsed 
mucous  membrane  was  strangulated  and  black.  It  was  excised,  and  no 
trouble  ensued.  Vascular  growth  of  the  meatus  urinarius  is  occasionally  met 
with  in  children  {vide  Eve,  '  Lancet,'  November  1889). 

We  have  seen  one  case  of  complete  absence  of  the  penis,  the  urethra 
opening  just  at  the  margin  of  the  anus,  outside  the  external  sphincter  ;  the 
scrotum  and  testes  were  well  developed.  The  child  was  under  the  care  of 
our  colleague,  Mr.  Collier.  For  an  account  of  other  malformations  of  the 
penis,  such  as  torsion,  adhesion  of  the  penis  to  the  scrotum,  double  penis, 
penile  fistula,  &;c.,  we  must  refer  to  Mr.  Jacobson's  work  on  '  Diseases  of 
the  Male  Organs.' 

Phimosis,  or  the  condition  where  a  long  prepuce  exists  which  cannot 
without  difficulty  be  drawn  back  over  the  glans  on  account  either  of  the 
small  size  of  its  orifice  or  because  of  adhesions,  is  an  affection  which  may 
be  congenital  or  acquired.  Further,  it  varies  much  in  degree  :  the  pre- 
puce may  be  very  long  and  end  in  a  puckered,  tapering  point,  in  which 
there  is  but  a  pin-hole  orifice.  Tanner  has  found  it  absolutely  imperforate. 
Where  the  opening  is  very  small,  when  urine  is  passed  it  collects  between  the 
glans  and  prepuce,  and  '  balloons '  out  the  latter,  or  the  prepuce  may  be 
tightly  stretched  over  the  glans  and  universally  adherent  to  it. 

In  most  children  at  birth  the  prepuce  entirely  covers  the  glans,  and  on 
withdrawing  it  adhesions  are  very  often  found  between  the  two,  while  the 
coronal  groove  is  filled  up  with  retained  smegma  in  round  lumps  ;  if  these 
adhesions  are  not  broken  dowii  and  the  glans  kept  clean,  secondary  inflam- 
mation is  apt  to  occur  (balanitis)  and  give  rise  to  still  further  adhesions,  with 
perhaps  increased  contraction  of  the  prepuce.  In  most  cases,  with  a  little 
trouble,  the  foreskin  can  be  drawn  back,  the  adhesions  being  torn  down  by 
the  finger  and  thumb  or  a  probe  ;  the  adhesions  are  frequently  non-vascular, 
at  other  times  a  few  drops  of  blood  escape.  Daily  retraction  and  cleanliness 
for  a  week  or  two  get  rid  of  all  further  trouble,  occasional  drawing  back 
and  washing  being  all  that  is  afterwards  required. 

If  phimosis  is  neglected,  many  ill  results  may  follow  :  retention  of  urine 
from  obstruction  at  the  preputial  outlet  or  at  the  meatus  ;  as  a  result  of  such 
contraction  extravasation  of  urine  may  occur,  or  incontinence  of  mine  from 
irritation.  Prolapse  of  the  rectum  and  hernia  may  result  from  the  straining 
required  to  empty  the  bladder  or  from  irritation  ;  while  cystitis,  balanitis, 
formation  of  preputial  calculi,  masturbation,  and  in  later  life  sterility  and 
increased   liability    to   venereal  diseases  and  epithehoma  may  result  from 

case,  treated  successfully  by  a  sort  of  forced  catheterism,  is  recorded  by  Forster,  of  Darling- 
ton, Brit.  Med.  Jour.  January  3,  1885  ;  also  Shattock,  Lancet,  February  11,  1888. 
^  Path.  Soc.  Travis,  vol.  xiv. 


Phimosis  623 

neglected  phimosis.  Other  troubles,  such  as  paraphimosis  if  a  tight  prepuce 
is  drawn  back,  and,  according  to  Mr.  Barwell's  view,  possibly  joint  lesions 
from  reflex  irritation,  may  occur.  Sayre  also  records  cases  of  various  con- 
tractions and  deformities  of  the  lower  limbs  resulting  from  phimosis. 

If  the  obstacle  to  retraction  is  simply  the  adhesions,  the  breaking  down 
of  these,  already  mentioned,  is  sufficient;  if,  however,  the  preputial  orifice 
is  tight,  circumcision  should  be  performed  in  infancy.  Dilatation  of  the 
prepuce  answers  in  some  cases  ;  but  we  are  strongly  opposed  to  it,  since  we 
have  seen  not  only  rapid  re-contraction  but  also  much  inflammation  set  up, 
necessitating  circumcision  and  a  long  delay  in  healing  ;  it  is  not  a  good  plan. 

In  any  doubtful  case  it  is  wiser  to  circumcise,  as  the  operation  is  as  harm- 
less as  any  operation  can  be  if  done  properly. 

In  every  male  infant  the  condition  of  the  prepuce  should  be  attended  to 
during  the  first  few  weeks  of  life  ;  much  subsequent  trouble  may  be  thereby 
avoided. 

There  are  many  ways  of  circumcising,  of  which  we  will  only  describe  the 
two  we  prefer.  Slitting  up  the  prepuce  should  never  be  done  in  children  :  it 
is  much  better  to  circumcise  properly. 

The  child  should  be  anaesthetised  and  then,  with  a  pair  of  dressing 
forceps,  the  prepuce  should  be  seized  just  in  front  of  the  glans,  but  it  is  not 
•  to  be  drawn  forwards  so  as  to  put  it  on  the  stretch,  or  too  much  skin  will  be 
removed.  The  forceps  should  be  held  vertically,  and  the  skin  in  front  of 
them  shaved  off  with  a  scalpel ;  but  at  the  lower  part  of  the  section  the 
knife  should  be  turned  forwards  so  as  to  make  a  little  triangular  tongue  of 
skin  projecting  from  the  cut  edge  of  the  prepuce  ;  the  dressing  forceps  are 
now  removed  and  the  skin  retracts  ;  the  mucous  membrane  is  next  slit  up 
along  the  upper  surface  of  the  glans  with  a  pair  of  scissors,  and  clipped  away 
all  round  as  far  as  the  frjenum,  leaving  enough  rim  of  mucous  membrane  to 
readily  hold  the  sutures  ;  th'e  frsenum  should  not  be  clipped  close  Inter- 
rupted catgut  sutures  are  used  to  stitch  together  skin  and  mucous 
membrane,  generally  one  on  the  dorsum  and  one  on  each  side  are  sufficient  ; 
the  little  tongue  flap  is  then  stitched  to  the  fr?enum  and  made  to  cover  in  its 
raw  surface  ;  by  this  means,  which  was  shown  us  by  Mr.  Davies  Colley  of 
Guy's  many  years  ago,  rapid  healing  is  usually  obtained  and  there  is  no  raw 
surface  to  granulate.  The  patient  should  be  kept  lying  down  for  a  few  days. 
We  often  slit  up  the  prepuce  with  scissors,  and  then  clip  away  the  required 
amount  of  skin  ;  by  this  means  it  is  easier  to  estimate  the  length  of  foreskin 
to  be  left.  It  is  better  to  do  without  any  dressing,  simply  keeping  the  clothes 
away  from  the  part  by  a  cradle.  If  there  is  any  troublesome  oozing,  a  strip  of 
lint  may  be  wrapped  round  the  penis,  leaving  the  meatus  exposed.  Bleeding 
should  be  carefully  arrested  before  putting  in  the  sutures.  Covering  over  the 
penis  with  a  thick  pad  of  cotton  wool  in  the  hollow  of  which  a  large  mass  of 
vaseline  has  been  put  is  a  good  plan  (Banks). 

In  a  perfect  circumcision  the  edge  of  the  prepuce  will  just  cover  the 
corona  ;  if  too  much  is  removed  the  corona  is  apt  to  remain  tender  and 
irritable  for  a  long  time.  If  catgut  sutures  are  used  they  do  not  require 
removal.  The  Jewish  mode  of  circumcision  does  not,  we  think,  give  such 
good  results  as  that  above  described.  Martin  alleges  that  circumcision 
may  produce  contraction  of  the  meatus,  as  a  result  of  exposure  and  friction, 


624         ■        Diseases  of  the  Genito-urinary  System 

and  various  secondary  reflex  irritations,  which  he  has  relieved  by  sUtting 
the  meatus  ;  but  we  doubt  the  occurrence  of  any  bad  result  from  circum- 
cision properly  performed,  and  think  any  such  troubles  are  more  likely  the 
result  of  the  condition  for  which  circumcision  is  done. 

Balanitis  is  often  met  with  in  children,  and  is  usually  the  result  of 
neglected  phimosis  ;  the  prepuce  may  be  much  swollen,  and  large  quantities 
of  pus  are  sometimes  discharged  from  within  it  ;  there  is  much  scalding 
pain  on  micturition.  Mild  cases  are  readily  cured  by  syringing  out  the  cavity 
beneath  the  prepuce  with  warm  water  or  lead  lotion.  As  soon  as  the  acute 
inflammation  has  subsided  circumcision  should  be  performed  ;  it  is  some- 
times necessary  to  circumcise  at  once,  but  in  such  cases  the  wound  is  apt  to 
be  slow  in  healing. 

The  trick  of  tying  a  string  or  tape  round  the  penis,  for  mischief,  or  to 
prevent  the  need  of  passing  ui'ine,  is  to  be  thought  of  in  cases  where  a  child 
is  brought  with  swelling  and  inflammation  of  the  penis  ;  the  string  may  be 
completely  buried  in  the  soft  parts,  and  may  give  rise  to  ulceration  or  even 
sloughing,  urinary  fistula,  &c. 

Congenital  paraphimosis  is  the  condition  where  the  glans  is  congeni- 
tally  uncoA'ered  by  prepuce  ;  it  is  not  a  very  common  condition,  but  is  always 
found  in  hypospadias,  even  in  the  slighter  degrees. 

Acquired  paraphimosis  is  produced  by  retraction  of  a  tight  prepuce,  so 
that  the  glans  is  exposed  ;  it  is  usually  the  result  of  mischievous  meddling 
with  the  penis.  If  the  prepuce  is  not  speedily  drawn  forward  again,  the  tight 
foreskin  constricts  the  penis  behind  the  corona  and  interferes  with  the  venous 
circulation  both  in  the  prepuce  and  the  glans  :  the  result  of  this  is  swelling 
and  pain,  the  swelling  being  chiefly  of  the  prepuce^  since  its  tissue  is  more 
lax  than  that  of  the  glans.  If  the  condition  is  neglected  the  appearance  be- 
comes somewhat  alarming  ;  there  is  much  oedema,  often  redness,  and  some 
ulceration  with  distortion  of  the  organ.  Since  the  constriction  is  tightest  on 
the  dorsum  of  the  penis,  there  is  little  or  no  risk  of  ulceration  into  the 
urethra,  and  still  less  of  complete  gangrene,  as  has  been  sometimes  stated, 
but  much  trouble  and  no  little  alarm  are  often  caused  by  this  condition,  and 
we  have  known  it  give  rise  to  suspicions  of  erysipelas  ;  it  might  also  possibly 
be  mistaken  for  extravasation  of  urine  or  cellulitis.  The  treatment  of  the 
affection  consists  in  drawing  forward  the  prepuce  again  ;  to  do  this  the 
swollen  foreskin  should  be  punctured  with  a  needle  and  all  the  serum  squeezed 
out  :  by  then  drawing  forward  the  prepuce  with  the  fore  and  middle  fingers 
of  both  hands,  at  the  same  time  pressing  back  the  glans  with  the  thumbs, 
reduction  can  be  accomplished,  unless  the  constriction  is  very  tight  or  of  long 
standing.  Another  method  consists  in  winding  a  piece  of  tape  or  narrow 
elastic  round  the  penis,  from  the  glans  backwards,  and  so,  by  reducing  the 
size  of  the  glans,  the  foreskin  can  be  brought  over  it.  Where  the  paraphi- 
mosis has  existed  for  more  than  a  few  days  it  may  be  irreducible  ;  or,  if  the 
constriction  is  very  tight,  it  maybe  necessary  to  divide  the  contracted  prepuce 
behind  the  corona,  but  this  is  rarely  required.  Under  such  circumstances 
the  sweUing  is  to  be  reduced  by  puncture  and  a  lead  lotion  dressing  applied  ; 
in  time  the  parts  will  model  down,  and,  though  permanent  paraphimosis 
usually  results,  no  serious  harm  occurs.     After  reduction  of  a  paraphimosis. 


Masturbation —  Vaginitis  62  s 

if  the  foreskin  is  long  and  tight,  circumcision  should  be  performed,  or  in  any 
case  measures  taken  to  prevent  a  repetition  of  the  retraction. 

Masturbation. — Masturbation  in  children  is  usually  the  result  of  a  long 
prepuce,  or  retained  secretion,  or  of  some  other  source  of  irritation  about 
the  pelvic  organs  in  either  sex,  such  as  worms,  balanitis,  vaginitis,  stone, 
&c.  The  treatment  obviously  in  such  cases  is  to  remove  the  source  of 
irritation  ;  circumcision  is  in  obstinate  cases  desirable,  both  as  a  means  of 
removing  irritation  and  as  a  deterrent,  while  in  older  children,  who  are 
able  to  understand  the  matter,  and  in  whom  the  habit  is  a  bad  practice  and 
not  the  result  of  any  obvious  physical  cause,  judicious  speaking,  pointing  out 
the  uncleanness  and  the  debasing  effect  of  the  act,  is  the  best  line  of  treat- 
ment. Coupled  with  these  plans  should  be  care  in  avoiding  opportunities 
and,  if  necessary,  punishment  should  the  vice  be  persisted  in.  In  all  cases 
onanism  should  be  treated  first  as  a  disease,  and  only  as  a  vice  when  it  is 
clear  that  no  cause  for  it  exists. 

(Edema  of  the  Scrotum  in  children  is  sometimes  met  with  apart  from 
any  obvious  inflammatory  condition  :  it  maybe  part  of  a  general  oedema  due 
to  cardiac  or  renal  disease  ;  in  other  instances  it  is  the  result  of  intertrigo, 
such  as  is  met  with  in  fat  and  dirty  children  ;  occasionally  it  occurs  without 
obvious  cause,  and  in  such  cases  some  source  of  obstruction  to  the  lymphatic 
or  venous  circulation  should  be  looked  for.  Erysipelas,  or  diffuse  cellulitis 
of  the  scrotum,  penis,  &c.  is  also  occasionally  seen.  In  all  these  conditions 
attention  to  the  general  health  and  the  use  of  lead  lotion  are  usually  all  that 
is  required. 

Diseases  of  the  External  Genitals  in  Females. — The  congenital  mal- 
formations of  the  external  genitals  of  female  children,  apart  from  so-called 
hermaphroditism,  are  rare,  with  the  exception  of  the  simple  adhesion  between 
the  labia  minora  of  the  two  sides,  which,  as  Mr.  Holmes  has  pointed  out,  if 
neglected,  may  produce  retention  of  menses  in  later  life,  and  probably  forms 
the  majority  of  the  cases  of  so-called  imperforate  hymen.  The  treatment  of 
adherent  la.bia  is  very  simple  ;  the  adhesions  are  broken  down  readily  with 
a  probe,  and  a  little  oiled  hnt  kept  between  the  labia  for  a  few  days,  together 
with  ordinary  cleanliness,  is  all  that  is  required. 

Hypertrophy  of  the  labia  or  clitoris  in  children,  though  common  among 
the  natives  of  some  hot  climates,  is  very  rare  in  this  countrj'.  We  have, 
however,  occasionally  seen  it,  though  rarely  to  an  extent  that  required  treat- 
ment. In  a  young  adult,  however,  we  have  had  occasion  to  remove  hyper- 
trophic labia,  the  condition  having  lasted  some  years,  but  whether  it  was 
congenital  or  not  we  cannot  say.  Nothing  short  of  operation  is  likely  to  be 
of  any  service.  We  have  recently  seen  a  case  in  which  the  clitoris  of  a  little 
child  was  much  enlarged  and  caused  irritation  ;  examination  showed  that 
there  was  adhesion  of  the  prepuce  of  the  clitoris  to  the  glans,  with  retained 
smegma,  just  as  in  the  case  of  phimosis  in  the  male. 

Naevus  of  the  labia  is  seen  every  now  and  then,  and  is  best  treated  bv 
puncture  with  the  actual  cauter}\ 

Of  acquired  affections,  simple  Vagrinitis,  or,  as  it  more  commonly  is  called, 
vulvitis,  is  frequently  met  with  ;  it  is  usually  caused  by  neglect  and  dirt, 
and  often  by  the  irritation  of  thread-worms,  but  is  sometimes  the  result  of 
inoculation  with  the  discharges  from  other  cases  of  vulvitis,  or  from  older 


626  Diseases  of  the  Genito-iwinary  System 

people  by  the  use  of  dirty  sponges  for  washing,  &c.  Very  rarely  indeed  is 
it  the  result  of  attempted  rape,  and  such  charges  are  often  brought  against 
innocent  persons  simply  because  the  mothers  conclude  that  all  discharges 
from  the  genital  organs  in  children  must  be  venereal  ;  and  it  should  be 
remembered  that  some  children  are  led  to  invent  stories  or  to  confirm 
suggestions  made  by  ignorant  or  dishonest  mothers.  Even  the  presence  of 
organisms  indistinguishable  from  gonococci  would  not  be  conclusive. 

This  simple  vulvitis  is  very  contagious  in  many  cases  and  readily  spreads 
from  one  child  to  another  ;  hence  isolation,  perfect  cleanliness,  the  removal 
of  sources  of  irritation,  and  the  free  use  of  antiseptic  lotions  such  as  per- 
chloride  of  mercury  or  boric  acid,  should  be  employed.  In  some  cases 
astringent  lotions,  such  as  sulphate  of  zinc  or  alum,  are  useful,  and  iodoform 
should  be  well  dusted  into  the  vulva.  In  one  instance  we  found  prominent 
masses  of  granulations  in  the  vagina  in  a  case  that  had  long  resisted  ordinary 
treatment  ;  in  this  case  nitrate  of  silver  proved  the  best  application. 

The  so-called  apbthous  vulvitis  is  a  superficial  ulceration  occurring  not 
rarely  about  the  labia  in  ill-nourished,  neglected,  and  unhealthy  children, 
especially  common  as  a  sequel  or  complication  of  one  of  the  exanthems.  It 
occurs  also  in  some  cases  of  nephritis,  and  may  simulate  the  severer  disease, 
noma,  from  the  presence  of  dried  blood  on  the  surface,  giving  the  appear- 
ance of  sloughing,  as  in  the  following  case  : 

Acute  Nephritis.  Ulceration  of  Labia. — Mabel  C. ,  age  2  3'ears.  Admitted  October  27, 
1885.  Two  months  ago  an  eruption  appeared  on  the  face  and  head,  which  has  lasted 
since  ;  for  the  past  fortnight  the  labia  have  been  swollen  and  sore,  small  spots  appearing 
first ;  has  had  epistaxis  for  the  last  few  days ;  is  said  not  to  have  passed  urine  since  the 
24th  ;  bowels  open  this  morning,  motion  quite  black.  On  admission,  pale,  pasty,  bloated 
child  ;  labia  both  much  swollen  and  superficially  ulcerated  ;  no  vaginal  discharge  ;  some 
superficial  ulceration  around  the  right  ear  ;  eczematous  patches  on  the  head,  covered  with 
blood-stained  scabs.  28th,  seems  very  feeble ;  no  urine  passed  until  this  morning,  and 
then  into  the  bed  ;  vulva  as  yesterday,  some  thread-worms  seen  about  it ;  eyes  puffy  ;  does 
not  take  food  well  ;  found  dead  in  bed  at  9  p.m.  The  %ailva  was  dressed  with  carbolic 
lotion  and  boric  lint,  and  carbonate  of  ammonia  and  bark,  with  strong  beef  tea  and 
wine,  given.     Temperature,  28th,  M.  98-2°,  E.  96  •6°. 

Post-mortem. — Both  lungs  rather  congested  and  cedematous  ;  no  pneumonia  ;  heart 
normal;  kidneys  swollen;  weighed  together  3  oz.,  not  verj'  congested;  in  one,  cortex 
finely  granular  (like  scarlatinal  nephritis)  with  red  points  ;  the  ulceration  on  the  vulva  and 
head  were  quite  superficial ;  there  was  no  sloughing  ;  it  extended  all  over  vulva  to  the 
vaginal  orifice. 

The  treatment  consists  in  cleanliness,  free  stimulation,  and  abundant 
nourishment,  together  with  such  measures  as  the  disease  with  which  it  is 
associated  demands. 

According  to  Savarin  aphthous  vulvitis  occurs  most  commonly  in  children 
of  from  two  to  five  years,  and  usually  is  a  sequel  of  measles  ;  the  patches 
begin  as  blisters  and  then  ulcerate  ;  they  may  finally  become  gangrenous. 
There  is  some  fever  and  the  parts  around  are  swollen,  but  there  is  very  rarely 
lymphatic  enlargement.  The  labia  majora  are  most  often  affected,  but  the 
process  may  spread  to  the  perinasum,  groin,  &c.  The  disease  has  a  certain 
resemblance  to  diphtheria  and  syphilis,  but  is  distinguished  from  the  former 
by  the  imperfect  membrane  formation,  and  from  both  by  the  multiplicity  of 
the   ulcers,  the  absence  of  lymphatic  enlargement,  and  the  history.     The 


Noma  Pudcndi — Irritable  Mamma  627 

prognosis  is  favouraljle  unless  gangrene  occurs,  and  the  best  applications 
are  boric  acid  and  iodoform. '  Tuberculous  ulceration  may  be  met  with 
about  the  vulva  as  in  other  parts. 

Noma  Pudendi.^ — Noma  pudendi  or  noma  vulva;  is  a  gangrenous  affec- 
tion of  the  external  genitals,  of  precisely  the  same  character  as  cancrum  oris  ; 
it  runs  in  similar  course,  occurs  under  the  same  conditions,  and  requires  the 
same  treatment.  It  is  quite  as  fatal  as  cancrum  oris,  if  not  more  so  ;  it 
is,  however,  much  rarer  :  many  of  the  cases  of  so-called  noma  are  merely 
aphthous  vulvitis.  We  have  very  rarely  seen  well-marked  cases.  Morse 
has  found  an  organism  in  noma  that  he  regards  as  pathogenic- 
Warty  and  cystic  growths  are  mentioned  by  Mr.  Holmes  and  others  as 
having  been  met  with  about  the  vulva  and  vagina  in  children,  and  would 
require  treatment  on  general  principles. 

Haemorrhage  from  the  vulva  or  vagina  is  occasionally  met  with  in  infants, 
but  is  of  trivial  importance  and  requires  no  treatment  (Holmes)  ;  vide  chapter 
on  Diseases  incidental  to  Birth. 

Irritable  ivcainnia. — Irritable  or  painful  mammje  are  not  uncommon  in 
girls  of  from  ten  to  fifteen  years.  There  is  slight  enlargement  of  the  glands, 
which  are  tender  ;  the  pain  is  variable  ;  usually  one  breast  is  affected  at  a 
time  and  the  other  is  attacked  later.  This  condition  is  usually  met  with 
before  menstruation  has  occurred,  but  is  probably  associated  with  the  physio- 
logical growth  of  the  organs.  A  similar  condition  is  met  with  to  a  less 
marked  degree  in  boys  about  puberty.  Occasionally  the  condition  is  simply 
hysterical.  Treatment  seems  to  be  of  little  use,  but  all  the  cases  we  have 
seen  have  got  well.  Belladonna  and  strapping  locally,  with  tonics  and  arsenic 
internally,  should  be  tried. 

In  infants  the  breasts  occasionally  suppurate  ;  this  is  usually  the  result 
of  rough  handling  on  the  part  of  superstitious  nurses,''  and  may  result  in  per- 
manently stunted  or  retracted  nipples. 

.A,l)noriuallties  in  the  Descent  of  the  Testicles. — In  the  fully  developed 
child  the 'testes  should  be  in  the  scrotum  at  birth,  or  rather  shortly  before 
birth  ;  ■*  it  is  not,  however,  rare  for  their  descent  to  be  delayed  for  varying 
periods — they  may  even  pass  into  the  scrotum  as  late  as  the  time  of  puberty. 
Most  commonly  descent  takes  place  between  the  second  and  tenth  years 
{Hunter,  quoted  by  Jacobson)  ;  if  the  testicle  does  not  come  down  by  the 
end  of  the  first  year.  Curling  says  it  is  usually  accompanied  by  a  hernia.  In 
some  instances  the  organs  are  permanently  retained  within  the  abdomen 
(cryptorchism) ;  sometimes  one  testicle  descends,  the  other  being  retained 
(monorchism).  When  the  testes  have  not  reached  their  proper  situation 
they  may  be  found  in  the  abdomen,  at  the  internal  ring,  in  the  inguinal 
canal,  in  the  upper  part  of  the  scrotum,  in  the  perinaeum,  or  even  in  the 
thigh  ;  '  and  instances  of  descent  of  the  testes  through  the  femoral  canal 

1  Vide  Savarin,  Rev.  Mens,  des  Malad.  de  V Enfance,  May  1884. 

2  Med.  Record,  January  1885. 

2  The  breasts  are  pulled  at  to  'break  the  nipple  strings,'  with  the  idea  of  preventing 
retraction  of  the  nipples  in  later  life. 

"^  Camper  found  the  testes  in  the  scrotum  at  birth  in  sixty-three  cases  out  of  seventy. 

•''  Displacement  of  the  testes  into  the  thigh  has  been  accounted  for  by  the  fact  that 
some  fibres  of  the  gubernaculum  testis  pass  downwards  into  the  upper  part  of  the  thigh. 

S  S  2 


628  Diseases  of  the  Genito-urinary  System 

are  on  record.  Usually  the  glands  are  movable,  and,  though  they  may 
generally  occupy  one  particular  position,  they  may  often  be  drawn  down 
or  pushed  up  beyond  that  spot,  just  as  their  situation  alters  according  to 
the  contraction  or  relaxation  of  the  cremaster  and  dartos  under  ordinary 
circumstances. 

The  cause  of  failure  of  natural  descent  of  the  testicles  is  still  somewhat 
obscure.  Possibly  failure  in  the  action  of  the  gubernaculum,  possibly  simply 
a  lack  of  development ;  certainly  sometimes  adhesions  to  surrounding  parts, 
to  the  funicular  process,  the  intestine,  or  the  mesentery,  prevent  the  descent. 
Premature  closure  of  the  funicular  process,  contraction  of  the  inguinal  rings, 
or  a  deficient  development  of  the  scrotum  in  some  cases,  perhaps  accounts 
for  the  failure  ;  other  less  frequent  causes,  such  as  shortness  of  the  vas 
deferens,  a  long  mesorchium,  allowing  the  testis  to  float  freely  in  the 
abdomen,  fusion  of  the  two  testes,  or  an  enlarged  epididymis,  are  mentioned 
by  Jacobson.^ 

The  condition  of  the  glands  when  they  are  in  an  abnormal  position  is  a 
question  of  importance  :  they  are  often  imperfectly  developed.  In  other 
cases,  however,  they  are  in  no  way  defective,  and  cryptorchism  by  no  means 
necessarily  implies  sterility,  while  monorchism  is,  of  course,  functionally  still 
less  important. 

Apart  from  functional  imperfection,  various  evils  may  attend  imjoerfectly 
descended  testes.  From  their  abnormal  position  and  diminished  mobility 
they  are  in  many  cases  more  exposed  to  injury,  as,  for  instance,  when  they 
are  lodged  in  the  perineum  or  in  the  canal.  If  a  testis  becomes  inflamed 
from  injury  or  other  cause,  the  symptoms  are  likely  to  be  much  more  serious 
if  the  gland  is  retained  within  the  abdomen  or  in  the  canal,  while  retained 
testes  are  said  to  be  frequently  the  seat  of  new  growths. ^  Most  important, 
perhaps,  of  all  is  the  effect  of  an  imperfect  descent  of  the  testicle  upon  the 
formation  and  persistence  of  hernia.  But  keeping  the  inguinal  canal  and 
rings  open,  the  misplaced  organ  directly  encourages  the  descent  of  a  hernia. 
Where  the  gland  acquires  adhesions  to  the  bowel  and  then  descends  into 
the  canal,  or  even  where  the  adhesions  result  from  descent  of  a  hernia  after. 
the  testis,  the  matter  is  still  further  complicated,  and  great  difficulty  in  the 
management  of  such  cases  may  arise.^  It  is  quite  common  for  a  child  to  be 
brought  with  the  statement  that  it  is  ruptured,  and  that  it  has  perhaps  been 
wearing  a  truss — but  this  is  said  to  have  been  always  painful,  and  the  child 
screams  all  the  while  it  is  on.  Examination  shows  an  undescended  testis 
lying  in  the  canal,  which  has  been  pressed  upon  by  the  truss,  and,  of  course, 
the  child  could  not  bear  it.  In  such  cases  the  undescended  testis  is  often 
the  supposed  hernia,  though  frequently  enough  the  two  conditions  co-exist, 
and  a  reducible  hernia  is  found  to  descend  above  the  testicle.     We  have 

1  Diseases  of  the  Male  Orgajis  of  Generation,  1893;  vide  also  Lockwood,  Brit  Med. 
Jour.  1887. 

2  Especially,  according  to  Virchow,  whea  they  are  retained  in  the  inguinal  canal ;  he 
points  out  that  obscure  abdominal  tumours,  in  the  absence  of  any  more  obvious  connec- 
tion, should  induce  examination  for  an  undescended  testis. 

^  The  caecum  may  descend  with  the  testis  in  consequence,  possibly,  of  unusual  strength 
or  abnormal  arrangement  of  that  portion  of  the  mesorchium  called  the  '  plica  vascularis ' 
{vide  Lockwood,  Med.  Chir.  Trans.  1886). 


L  Undescended  Testis 


629 


met  with  a  case  in  whicli  Ijoth  testis  and  hernia  were  strangulated  ;  we 
removed  the  testis,  closed  the  canal,  and  the  patient  made  a  good  recovery. 
The  late  Mr.  John  Wood  made  some  valuable  remarks  upon  this  subject  in 
his  lectures  published  in  the  '  British  Medical  Journal,'  June  1885.  Where  a 
hernia  and  an  imperfectly  descended  testis  co-e.\ist,  the  gland,  if  wasted,  may 
be  removed  ;  if  adherent  to  the  bowel  it  may  be  returnedjwithin  the  alidomcn, 
and  the  ring  closed,  or,  if  possible,  may  be  separated,  drawn  down  into  the 
scrotum,  and  fixed  there,  the  sac  and  canal  being  closed  above  it.  In 
funicular  hernia  a  tunica  vaginalis  may  be  made  by  detaching  part  of  the 
funicular  process,  and  bringing  it  down  into  the  scrotum  ;  if  the  cord  cannot 
be  drawn  out  enough  to  let 
the   gland   come   down,    the  /-^H^ 

epididymis  may  be  loosened 
from  the  testis,  and  the  latter 
turned  down  so  as  to  reach  the 
scrotum.  All  Mr.  Wood's  re- 
sults in  these  operations  were 
'  good,'  with  one  exception. 
The  diagnosis  of  undescended 
testis  is  not  often  a  matter  ot 
difficulty  :  an  examination  of 
both  sides  of  the  scrotum  will 
generally  clear  up  the  case. 
But  we  would  suggest  a  word 
of  caution  not  to  be  satisfied 
with  too  cursory  an  investiga- 
tion :  sometimes  one  testis 
maybe  down,  and,  unless  both 
are  felt  for  at  the  same  time, 
may  slip  about  so  as  to  feel  as 
if  it  belonged  to  either  side  ; 
sometimes,  too,  an  empty 
scrotum  may  be  felt,  but  a 
little  examination  and  mani- 
pulation of  the  canal,  or  the 
application  of  heat,  may  bring 
down  the  testicle,  and  the  case 
may  turn  out  to  be  merely  one  of 
retracted,  not  retained,  testis. 

Occasionally  a  hernia,  if  it  contains  thickened  omentum  or  glands,  may 
be  taken  for  a  testicle  or  a  hydrocele  of  the  cord,  or  a  fibrous  or  fatty  tumour 
may  simulate  a  testis  in  the  canal.  There  is  considerable  variation  in  the 
size  and  firmness  of  the  testes  of  young  children,  and  we  have  freciuently 
seen  mistakes  made  about  these  conditions. 

The  treatment  of  undescended  testicle  is  an  important  and  difficult 
matter.  Where  in  an  infant  or  child  three  or  four  years  old  there  is  an 
undescended  or  imperfectly  descended  testicle,  with  no  hernia,  nothing 
should  be  done  except  gentle  attempts  to  bring  the  glands  further  down  by 
pressure  from  above  with  the  fingers  ;  this  manipulation  should  be  repeated 


Fig.  136. — The  right  testis  is  undescended,  and  is  seen 
forming  a  swelling  in  the  inguinal  canal. 


630  Diseases  of  the  Genito-urinary  System 

frequently  during  the  day.  In  an  older  child,  up  to  the  age  of  puberty,  the 
same  line  of  treatment  should  be  adopted  as  a  rule  ;  if,  however,  the  testicle 
gives  rise  to  pain  or  trouble,  an  attempt  may  be  made  by  operation  to  bring 
it  down  and  fix  it  to  the  bottom  of  the  scrotum.  Mr.  Wood  had  some 
successes,  as  already  stated  ;  we  have  performed  the  operation  in  a  good 
many  cases,  but  though  it  is  sometimes  successful  we  have  found  that  there 
is  a  great  tendency  for  the  testes  to  again  become  retracted.  The  scrotum 
in  such  cases  is  often  small  and  ill  developed.  The  operation  consists  in  • 
exposing  the  testis  as  in  an  operation  for  hernia,  and  passing  a  silk  or 
catgut  stitch  through  its  outer  tunic,  or  between  the  gland  and  the 
epididymis,  and  then  bringing  the  suture  out  at  the  bottom  of  the  scrotum 
and  fixing  it  there.  Testis  in  perinEeo  is  probably  best  treated  by  replacing 
it  in  the  scrotum — by  operation,  if  possible  ;  if  not,  and  its  presence  gives 
rise  to  trouble,  it  should  be  removed.  Mr.  Jacobson  advises  that  all  such 
operations  should  be  postponed  till  after  the  first  or  second  year.  It  is 
essential  to  freely  separate  the  testis  from  all  the  adhesions  which  usually 
exist,  so  that  it  lies  quite  readily  in  its  new  position,  even  before  it  is 
stitched  there.  The  adhesions  may  be  remains  of  that  part  of  the  guber- 
naculum  which  is  attached  to  the  tuberosity  of  the  ischium,  and  this  may 
explain  the  abnormal  position  of  the  testis.^  Displacement  of  the  testicle 
into  the  perinasum  is  sometimes  the  result  of  dislocation,  and  is  not  con- 
genital :  under  such  circumstances  it  has  been  successfully  replaced.^ 

We  must  strongly  protest  against  the  use  of  a  truss  for  undescended 
testis  in  young  children  with  a  view  of  keeping  it  out  of  the  way,  or  preventing 
the  descent  of  a  hernia  where  no  rupture  already  exists  ;  we  cannot  but  con- 
sider the  plan  unnecessary  and  unscientific  except  in  the  cases  where  the 
testicle  is  inseparably  adherent  to  the  bowel,  and,  as  this  can  only  be  ascer- 
tained by  operation,  we  think  it  is  wiser  to  operate  in  doubtful  cases,  separate 
the  testis,  bring  it  down,  and  close  the  canal  above  it  if  possible.  If  this  cannot 
be  done,  the  testicle  should  either  be  removed — which  should  be  only  done, 
as  a  rule,  when  the  testicle  is  small  and  wasted,  and  can  be  separated  from 
the  gut  without  risk  of  injury  to  the  bowel — or,  after  reducing  it  into  the 
abdomen,' the  canal  should  be  closed  ;  hence  it  is  only  in  such  cases  that 
any  obstacle  to  the  descent  of  the  testicle  should  be  interposed. 

Should  an  undescended  testis  become  inflamed  from  injury,  from  torsion 
or  from  pressure  while  in  the  canal,  the  symptoms  may  be  severe,  and  may 
simulate  those  of  strangulated  hernia — the  absence  of  the  gland  from  the 
scrotum  usually  clearing  up  the  doubt  ;  if,  however,  there  is  any  uncertainty 
about  it,  or  the  symptoms  do  not  speedily  subside,  the  parts  should  be  ex- 
plored, and  the  inflamed  or  gangrenous  testis  is  generally  better  removed. 
Fatal  peritonitis  has  resulted  from  this  condition. 

Jacobson,  in  his  well-known  article  in  Holmes'  '  System  of  Surgery  '  and 
book  on  '  Diseases  of  the  Male  Organs,'  advises  the  use  of  Dover's  powder, 
hydrarg.  c.  creta,  and  hot  poppy  fomentations  in  these  cases  in  the  early 
stage  ;  to  this  work  we  must  refer  for  further  details  on  this  subject  :  to  it 
we  are  indebted  for  many  of  the  points  in  the  present  chapter. 

Where  a  hernia  co-exists  with  an  undescended  testis,  but  the  two  are  not 
1    Vide  Lockwood,  Med.  Chir.  Trans.  1886. 
^  Victor  Horsley,  Med.  Times  and  Gazette,  December  1883. 


,     Displaced  Testis — Supermimeraiy   Testicles  631 

adherent,  the  best  treatment  is  to  apply  a  truss  of  special  size  and  shape  for 
the  particular  case,  made  so  as  to  fit  between  the  testis  and  the  canal,  and  so, 
while  the  rupture  is  kept  up,  the  testis  is  pressed  downwards.  We  have 
employed  this  plan  usefully,  and  by  its  means  both  defects  may  be  cured. 
Should  the  truss  fail  to  procure  closure  of  the  canal,  the  hernia  should  be 
dealt  with  by  the  operation  described  in  p.  159  ;  the  funicular  process  being 
closed  above  the  gland,  the  descent  of  the  testis  will  be  favoured,  and  an 
attempt  may  be  made  at  the  same  time  to  fix  it  in  the  scrotum. 

Supernumerary  testicles  hardly  ever  occur.  Most  of  the  supposed  in- 
stances have  turned  out  to  be  either  hydroceles  of  the  cord,  hernia;,  or  solid 
tumours.  Lane  has,  however,  i-ecorded  a  recent  case.  Congenital  absence 
of  the  testes  as  distinguished  from  mere  cryptorchism  is  an  exceedingly  rare 
condition  and  usually  associated  with  other  malformations. 

Deficiency  or  closure  of  the  vas  deferens  is  occasionally  met  with  :  in 
such  cases  the  testis  is  well  developed,  but,  of  course,  functionless.  Inverted 
testicle,  where  the  epididymis  lies  in  front  of  the  gland,  is  sometimes  a  con- 
genital, sometimes  an  acquired  condition  ;  it  may  be  of  importance  in  case 
of  the  appearance  of  a  hydrocele  or  hernia,  or  as  a  predisposing  cause  of 
torsion  of  the  testicle. 

Mr.  Jacobson's  table  of  the  complications  of  misplaced  testis,  in  so  far  as  it  relates  to 
children,  is  here  summarised  : 

1.  The  testis  may  be  retained  [a]  in  the  abdomen,  (/')  in  the  iliac  fossa,  [c]  in  the 
inguinal  canal,  [d)  just  outside  the  external  ring. 

2.  The  testis  may  take  an  abnormal  course  into  [a)  the  perinseum,  [b]  the  crural 
canal. 

3.  Retained  testis  may  become  inflamed  or  gangrenous,  may  give  rise  to  peritonitis, 
may  simulate  a  strangulated  hernia,  or  may  become  the  seat  of  tuberculous  disease,  or 
of  malignant  growth,  or  may  atrophy. 

4.  Misplaced  testis  may  be  complicated  with  hernia,  (a)  from  adhesion  of  intestine  to 
the  undescended  testicle,  or  {b)  from  co-existing  patency  of  the  funicular  process. 

5.  Hydrocele  may  be  a  complication,  as  [a]  an  acute  condition  from  inflammatory 
effusion  into  .some  unobliterated  portion  of  the  processus  vaginalis,  or  [b)  as  a  chronic 
effusion  ;  in  either  case  there  may  be  a  communication  with  the  cavity  of  the  peritoneum 
above,  or  extension  into  the  scrotum  below. 

Congenital  displacement  or  Hernia  of  the  ovary  sometimes  occurs, 
one  or  both  organs  protruding  into  the  inguinal  or  even  into  the  femoral 
canals,  and  occasionally  in  later  childhood  a  similar  malposition  occurs.  We 
have  seen  both  ovaries  prolapsed  into  the  inguinal  canals  in  a  case  of  tuber- 
cular ascites,  the  ovaries  returning  to  the  abdomen  on  the  subsidence  of  the 
fluid.  If  irreducible,  the  ovaries  may  give  rise  to  trouble  in  later  life  from 
their  enlargement  at  the  menstrual  periods,  as  well  as  from  their  presence 
keeping  the  inguinal  canals  patent :  hence,  where  possible,  they  should  be 
returned  to  the  abdomen  and  kept  back  by  a  truss  ;  occasionally  an  opera- 
tion as  for  hernia  is  required.  Torsion  of  an  ovary  prolapsed  through  the 
inguinal  canal  has  been  recorded. 

Diseases  of  the  Testicle  in  Childhood. — Simple  acute  orchitis  in 
children  occurs  as  a  result  of  injury — undue  pressure  of  a  truss — or  the  result 
of  an  operation  such  as  that  for  the  radical  cure  of  hernia  or  lithotomy  ;  some- 
times without  assignable  cause,  or  under  circumstances  mentioned  in  the 
case  of  hydrocele.     The  inflammation  often  results  in  the  development  of 


632  Diseases  of  tJie  Genii o-ui'inary  System 

hydrocele,  and  there  is  often  oedema  of  the  scrotum  ;  but  the  affection  is 
seldom  severe,  and  subsides  readily  under  the  use  of  lead  lotion,  rest,  and 
elevation.  We  have  never  seen  any  immediate  bad  result,  though  it  is 
possible  that  the  subsequent  growth  of  the  gland  may  be  interfered  with. 
Orchitis  from  mumps  is  very  rare  in  childhood  ;  we  have  never  seen  it. 
Acute  inflammation  of  the  testis  going  on  to  gangrene  may  be  a  result  of 
'  torsion  '  of  the  testis,  an  accident  occasionally  met  with,  usually  occurring 
in  cases  in  which  there  is  some  abnormality  of  the  organ,  and  very  apt  to  be 
mistaken  either  for  an  acute  orchitis  from  some  other  cause,  or  for  strangu- 
lated hernia,  especially  if,  as  is  often  the  case,  the  testis  has  imperfectly 
descended.     Chronic  orchitis  may  result  from  the  acute  form. 

Sypbllitic  Testitis  is,  in  our  experience,  very  rare  ;  Mr.  Holmes 
mentions  having  seen  hard  knots  in  the  testicle  which  were  apparently 
gummatous  ;  they  readily  yield  to  the  use  of  hydarg.  c.  creta.  Other  cases 
have  also  been  recorded,  and  sometimes  a  diffuse  orchitis  is  found.  We 
have  met  with  cases  of  induration  of  the  testes  in  young  children  for  which 
we  have  been  unable  to  account. 

Tuberculous  disease  of  the  testicle  is  met  with  in  two  forms  :  as  a  pail 
merely  of  a  general  tuberculosis,  and  as  a  localised  condition  limited  to  the 
testis  alone  or  the  genito-urinary  tract.  Genito-urinary  tuberculosis  is  much 
rarer  in  children  than  in  adults,  but  it  is  common  to  find  both  testes  tubercu- 
lous. In  the  former  case  the  tubercles  may  be  only  miliary  and  disseminated, 
and  hence  not  recognisable  during  life,  or  they  may  form  definite,  hard, 
circumscribed  masses  in  the  epididymis,  just  as  in  adults.  While  the  disease 
is  limited  to  the  testicle,  it  takes  the  form  just  described,  giving  often  a 
sensation  as  of  a  '  dumb-bell'  or  double  testicle  ;  it  is  usually  not  painful,  and 
often  of  slow  growth.  If  nothing  cuts  short  the  child's  life,  the  testicle 
usually  at  last  breaks  down,  and  a  suppurating  '  strumous  testis '  develops, 
with  its  characteristic  adherent  or  undermined  skin,  livid  colour,  and 
intractable  course  ;  the  cord  is  usually  thickened. 

Where  the  tubercle  is  generalised,  no  treatment  of  the  testicular  affection 
is,  of  course,  of  any  use  ;  when,  however,  no  obvious  lesion  exists  elsewhere, 
the  usual  management,  medicinal  and  dietary,  of  these  cases  should  be 
carried  out  (cod  liver  oil,  phosphate  of  iron,  &c.).  For  the  testicle  itself, 
pressure,  with  occasional  inunction  of  mercurial  or  iodide  of  lead  ointment, 
may  be  used,  but  as  soon  as  suppuration  occurs  it  is  probably  better  to 
remove  the  gland  ;  it  is  in  such  cases  most  likely  functionally  destroyed  from 
blockage  of  the  efferent  ducts,  and  is  a  source  of  general  infection.  The 
operation  is  sometimes  advised  as  a  precautionary  measure  as  soon  as  a 
diagnosis  can  be  made,  but  the  propriety  of  this  we  think  open  to  doubt ;  we 
have  had  occasion  to  perform  the  operation  only  once  or  twice,  and  in  one 
case  the  child  was  seen  two  or  three  years  later  in  good  health,  his  brother 
being  affected  by  '  general  surgical  tuberculosis.'  In  this  instance  the 
disease  began  at  7  weeks  old,  and  the  gland  was  removed  at  18  months  ; 
testicle  and  epididymis  were  involved.  Our  colleague.  Professor  Dreschfeld, 
has  recorded  a  case  of  congenital  tuberculosis  of  the  testis  in  which  tubercle 
bacilli  were  found.*  Hernia  testis  occurs  only  in  those  cases  where  the 
body  of  the  testis  is  involved,  and  when  present  castration  is  probably  the 
1  Brit.  Med.  Jour.  1884,  p.  860. 


Ttunoms  of  the   Testis  633 

wisest  course.  Occasionally  the  tubeiciilar  deposit  gives  rise  to  acute 
inflammation. 

Tumours  of  the  Testis. — Tumours  of  the  testis  in  children  may  be 
congenital  or  acquired  ;  the  congenital  are  rare  and  usually  teratomata  or 
*  dermoid,'  consisting  of  cysts  which  contain  hair,  teeth,  &c.  as  in  the 
corresponding  tumours  of  the  ovary.^  Striped  and  unstriped  myomata, 
however,  also  have  been  found,'-  as  well  as  congenital  adeno-sarcomata,^  and, 
according  to  Silcock,*  carcinoma — though  Butlin  disbelieves  in  the  occur- 
rence of  carcinoma  testis  in  children. 

Acquired  tumours  are  usually  sarcomata  (round-celled),  very  rapidly 
growing,  very  malignant,  and  tending  to  involve  the  lumbar  glands  very 
early.  The  large  size,  rate  of  growth,  solidity,  dilated  veins,  opacity,  and 
bossy  surface  sometimes  with  cysts,  make  the  diagnosis  usually  easy.  These 
growths  generally  occur  in  the  first  few  years  of  life,  but  according  to  Butlin 
are  common  from  the  time  of  birth  to  the  tenth  year. 

Non-sarcomatous  cystic  disease  may  be  met  with  ;  the  cysts  usually 
arise  as  dilatations  of  the  seminal  tubules,  and  may  be  lined  by  cylindrical 
or  ciliated  epithelium.  Immediate  removal  is  the  only  treatment  to  be  adopted 
in  a  case  of  malignant  disease  of  the  testis,  though  recurrence  within  a  year 
is  to  be  expected  in  most  cases  ;  in  simple  cystic  disease  the  same  treatment 
is  required,  since  a  diagnosis  between  it  and  sarcoma  is  impossible.  In  the 
case  of  dermoid  cysts  it  is  sometimes  possible  to  dissect  away  the  cysts 
without  injury  to  the  testis.-" 

Hydrocele. — Hydrocele  is  a  very  common  affection  in  childhood,  most 
frequently  met  with  in  quite  early  infancy  ;  it  may  result  from  simple  irrita- 
tion, intertrigo,  &c.,  especially  when,  as  is  often  the  case  in  that  condition, 
the  testes  hang  loose  and  pendulous.  It  is  sometimes  caused  by  injury,  the 
testis  being  squeezed  by  the  child  while  keeping  its  legs  crossed,  or  by  other 
accidents.  Hydrocele  may  be  congenital  where  the  whole  processus  vaginalis 
remains  patent  ;  in  this  case  if  the  communication  with  the  peritoneal  cavity 
remains  free,  the  fluid  will  flow  in  and  out  according  to  the  position  of  the 
child.  We  must  say  this  condition  is  not  often  found  :  either  the  opening  is 
a  small  one  and  readily  occluded  by  flexion,  or  this  form  of  hydrocele  is  rarer 
than  is  commonly  supposed. 

Infantile  hydrocele,  so  called,  is  the  condition  where  the  tunica  vaginalis 
and  funicular  process  are  distended  with  fluid,  the  processus  being  closed  at 
the  internal  ring-  ;  this  is  a  common  condition.  Again,  the  funicular  part  of 
the  processus  may  remain  open,  but  be  shut  off  from  the  tunica  vaginalis  ; 
in  such  a  case  a  congenital  funicular  hydrocele  would  result.  Or,  finally, 
there  may  be  an  encysted  hydrocele  of  the  cord  from  distension  of  an  unclosed 
segment  of  the  funicular  process. 

Diffused  hydrocele  of  the  cord,  described  as  a  sort  of  oedema  of  the 

1  Teratomatous  tumours  of  the  testis  are  explained  by  Saint-Hilaire  as  instances  of 
'  foetal  inclusion  ; '  by  Owen  as  instances  of  parthenogenesis  ;  and  by  Lebert  as  the 
result  of  '  h^t^rotopie  plastique.' 

^  Rindfleisch  and  Rokitansky.  ^  R.  W.  Parker,  Path.  Soc.  Trans.  1885. 

■i  Path.  Soc.  Trans.  1885. 

^  Verneuil,  Brit.  JMed.  Jour.  April  4,  1885.  For  a  full  account  of  testicular  growths 
seejacobson,  op.  cit. 


634 


Diseases  of  the  Genito -urinary  System 


cellular  tissue  of  the  cord,  is  believed  to  be  very  rare  ;  we  met  with  a  case 
while  operating  for  hydrocele  of  the  cord,  in  which  there  was  some  gelatinous 
material  lying  in  the  tissue  of  the  cord,  superficial  to  the  funicular  process, 
which  contained  ordinary  clear  fluid.  Hydrocele  (encysted)  of  the  testis, 
and  epididymis  from  dilatation  of  the  hydatid  of  Morgagni,  or  organ  of 
Giraldes,  may  possibly  occur;  it  is,  however,  usually  a  disease  of  later  life, 
and  no  case  appears  to  have  been  recorded  in  childhood.     (Gosselin.) 

Diagnosis. — The  diagnosis  of  hydrocele  in  children  is  made  by  first 
examining  the  cord,  and  excluding  the  presence  of  a  hernia  by  finding  that 
there  is  no  increased  thickness  of  the  cord  above  ;  next,  a  soft,  elastic,  fluc- 
tuating feeling  points  to  hydrocele  ;  and,  finally,  translucency,  or  the  possibility 
of  reduction  gradually  by  pi'essure  or  elevation,  without  any  gurgling  sensa- 
tion, clears  up  the  case.  It  is,  however,  certain  that  hernise  in  infants,  when 
the  bowel  contains  only  flatus  and  is  much  distended,  are  sometimes  quite 
translucent.  Mr.  Howse  was,  we  believe,  the  first  to  point  out  this  fact, 
and  we  have  many  times  seen  the  same  thing. 

When  there  is  an  encysted  hydrocele  of  the  cord  it  is  usually  possible 
to  bring  it  down  by  traction,  and  feel  the  absence  of  thickening  above,  or  the 
tense  swelling  may  be  made  to  slip  backwards  and  forwards  between  the 


Congenital 
funicular  form. 


Encysted  hydro- 
cele of  the  cord. 


Common  vaginal 
hydrocele. 


Fig.  137.- 


-Diagram  of  the  commoner  forms  of  Hydrocele  of  the  Vaginal  Process. 
Altered  from  Lane. 


fingers,  quite  unlike  a  hernia.  The  mode  of  reduction  serves  to  distinguish 
a  funicular  hernia  from  a  funicular  hydrocele,  and  the  absence  of  distinct  im- 
pulse gives  corroborative  evidence.  Hydrocele  of  a  retained  testis  sometimes 
occurs  and  may  give  rise  to  difficulty  ;  the  possibility  of  isolating  it,  its  irre- 
ducibility,  and  its  consistence,  together  with  the  absence  of  the  testis  from 
the  scrotum,  will  give  the  clue. 

Combinations  of  two  forms  of  hydrocele,  e.g.  of  vaginal  hydrocele  with 
encysted  hydrocele  of  the  cord,  may  be  met  with,  and  a  funicular  process 
may  contain  fluid  at  one  time  and  a  hernia  at  another.  Or  there  may  be 
infantile  hernia  with  infantile  hydrocele.  A  collection  of  fluid  may  form  in  the 
sac  of  a  congenital  hernia,  but  is  usually  masked  by  the  presence  of  bowel. 

Engel  and  Camper  are  quoted  by  Jacobson  as  having  found  the  processus 
vaginalis  closed  at  birth  in  about  10  per  cent,  only  of  children  examined  ;  this 
supports  the  view  that  some  abnormal  condition  of  secretion  in  the  abdo- 
minal cavity  must  exist  to  produce  a  congenital  hydrocele,  for  it  is  certainly 
not  as  common  as  these  figures  would  imply. 

Hydrocele  in  Girls. — The  funicular  process  in  girls  (canal  of  Nuck)  is 
occasionally  the  seat  of  hydrocele  ;  the  diagnostic  points  and  treatment  are 
practically  those  of  hydrocele  of  the  cord  in  boys. 


Hydrocele  in  Girls — Varicocele — Ovarian    Twnours      635 

TreaiiiienL — Many  cases  of  hydrocele  get  well  without  treatment  ;  those 
due  to  local  irritation  subside  on  removal  of  the  cause.  The  congenital  form 
may  disappear  by  spontaneous  closure  of  the  funicular  process  ;  other  cases 
subside  under  the  use  of  evaporating  lotions,  lead  lotion,  or  mild  counter- 
irritation  such  as  painting  with  tincture  of  iodine.  The  congenital  and  funi- 
cular varieties  are  usually  cured  by  a  truss,  and  it  is  seldom  that  hydroceles 
give  much  trouble.  When,  however,  these  plans  fail,  the  methods  of  treat- 
ment we  prefer  are  :  (i)  injection  with  solution  of  pure  carbolic  acid  in  glyce- 
rine (i  part  in  3)  without  emptying  the  sac  of  its  fluid,  so  that  the  injection 
is  still  further  diluted  ;  (2)  simple  antiseptic  incision  :  the  sac  is  laid  open  and 
drained  for  four  or  five  days  without  any  stitching  of  the  edges  of  the  sac  to 
the  skin,  as  in  the  so-called  '  schnitt  operation,'  or  part  of  the  parietal  layer 
of  the  tunica  may  be  excised,  and  so  the  sac  may  Idc  obliterated.  Tapping, 
subcutaneous  punctm-e,  letting  the  fluid  escape  into  the  loose  scrotal  tissue, 
setons,  injection  with  iodine  or  spirit,  &c.,  all  have  their  advocates,  and  are 
no  doubt  often  successful  ;  but  the  plans  mentioned  are  in  our  opinion  the 
safest,'  surest,  and  quickest,  though  relapses  occasionally  occur,  whatever 
method  is  adopted.  We  have  seen  a  hydrocele  develop  some  time  after  an 
operation  for  the  radical  cure  of  hernia  in  an  infant  in  whom  the  bowel  was 
strangulated. 

Qidema  of  the  scrotum  is  often  met  with  as  a  result  of  intertrigo  in 
children,  and  should  be  distinguished  from  hydrocele,  anasarca,  erysipelas, 
and  extravasation  of  urine — also  from  the  '  inflammatory '  or  '  malignant 
oedema,'  so  called. 

Varicocele  has  been  met  with  in  childhood  by  Bryant,  Pearce  Gould, 
and  Landouzy,  but  we  have  never  seen  a  case  earlier  than  about  the  tenth 
year,  though  we  have  seen  a  boy  of  thirteen  with  a  large  varicocele  which 
was  said  to  have  existed  for  five  years. 

Ovarian  Tumours  in  children  are  nearly  always  sarcomata,  teratomata, 
or  dermoid  cysts  ; '~  they  may  appear  at  any  age  :  thus  Chiene  '  has  operated 
successfully  at  three  months,  and  Roemer  *  of  Berlin  at  twenty  months.  The 
only  treatment  is  abdominal  section  in  the  ordinary  way.  In  the  case  of 
large  tumours  it  may  be  impossible  to  make  an  accurate  diagnosis  between 
ovarian  and  renal  or  other  congenital  tumours  until  the  abdomen  is  opened. 
Precocious  puberty  has  in  some  instances  been  found  associated  with  ovarian 
tumours.  We  have  seen  considerable  development  of  the  external  genitals, 
with  growth  of  hair  and  discharge  of  blood  from  the  vagina,  in  a  child 
three  years  old,  who  was  the  subject  of  a  tumour  which  apparently  involved 
the  liver  and  the  right  kidney.  Tuberculous  pyosalpinx  has  once  been  met 
with  by  Chaffey,  and  once  by  Quarry  Silcock.'' 

1  Poland  has  recorded  a  case  of  fatal  peritonitis  after  tapping  a  congenital  hydrocele 
of  the  cord. — Lancet,  December  1884. 

^  Evers,  St.  Louis  Courier  of  Medicine,  August  1884,  has  met  with  a  case  of  sarcoma 
in  a  girl  of  two  and  a  half  years. 

^  Edinburgh  Med.  Jour.  June  1884. 

4  Jahrbuchf.  Kindcrheilk.  Bd.  xxi.  H.  4.  Eight  out  of  eleven  cases  collected  by 
Roemer  recovered. 

5  Path.  Sac.  Trans.  1885.     See  also  Tumours  of  the  Ovary  b'c.  by  Doran. 


6t,6  Diseases  of  the  Bones 


CHAPTER   XXIX 

DISEASES   OF   THE   BONES 

Diseases  of  the  Bones. — A  full  description  of  the  subject  of  inflamma- 
tion in  bone  would  be  out  of  place  in  the  present  work,  but  a  few  of  the  more 
important  points  may  be  summarised  thus  : 

The  process  of  inflammation  as  occurring  in  bone  differs  from  that  in  the 
soft  parts  only  in  that  the  inflamed  tissue  is  more  rigid  and  unyielding  ;  hence, 
on  the  one  hand,  the  progress  of  inflammation  may  be  slower,  and  on  the 
other,  as  tension  is  greater,  its  effects  may  be  more  destructive. 

As  elsewhere,  inflammation  in  bone  leads  to  rarefaction,  i.e.  absorption  of 
healthy  tissue  (rarefying  ostitis),  and  this  may  go  on  slowly,  and  without  any 
sufficient  outpouring  of  material  to  develop  pus  or  any  obvious  external 
signs  of  the  changes  going  on.  The  bone  slowly  becomes  thinner  and 
weaker,  and  its  tissue  may  entirely  disappear  ;  such  a  change  we  see  in 
the  caries  sicca,  or  non-suppurative  caries,  of  the  vertebrfe  or  of  the  articular 
ends  of  the  long  bones.  It  is  in  some  cases  accompanied  by  a  deposit  of 
new  periosteal  bone  while  rarefaction  is  going  on  in  the  interior  ;  such  a 
condition  occurs  in  some  instances  of  chronic  osteomyelitis  of  the  shaft  of 
the  femur  after  excision  in  hip  disease.  In  these  cases  fractures  may  occur 
almost  spontaneously,  or  at  least  from  very  slight  violence. 

Again,  in  other  instances,  the  inflammatory  material  may  be  in  sufficient 
quantity,  and  so  incapable  of  becoming  organised  that  pus  is  formed,  and 
this  may  infiltrate  the  adjacent  bone,  and  so  give  rise  to  further  extension  of 
the  process,  without  the  formation  of  any  definite  abscess  ;  such  a  condition 
we  see  in  some  of  the  cases  of  chronic  osteomyelitis  of  the  long  bones, 
epiphysitis,  certain  forms  of  necrosis  of  the  jaw,  &c.  Under  these  circum- 
stances necrosis  usually  results,  or  if  there  is  more  abundant  pus  formation 
an  abscess  in  bone  is  found. 

Where,  in  consequence  perhaps  (Cornil  and  Ranvier)  of  primary  fatty 
degeneration  of  bone  corpuscles^  the  bone  tissue  slowly  dies,  the  dying  part, 
acting  as  an  irritant,  gives  rise  to  inflammation  around,  and  the  bone  is  slowly 
disintegrated,  with  more  or  less  abundant  formation  of  pus  ;  such  a  process 
is  seen  in  ordinary  caries  of  a  rib  or  of  the  pelvis,  or  of  the  articular  end  of  a 
bone.  When  small  islets  of  bone  are  marked  out  and,  as  it  were,  cut  off  from 
the  rest  by  the  surrounding  inflammation,  minute  sequestra  become  de- 
tached (caries  necrotica),  while,  if  larger  masses  are  so  separated  by  a  line 
of  demarcation,  common  necrosis  results.  The  last-named  may,  of  course, 
be  an  acute  or  chronic  process,  a  slow  diminution  in  blood  supply  causing 


Acute  Periostitis  637 

gradual  starvation,  or  an  immediate  strangulation  causing  rapid  gangrene 
of  the  part  (acute  necrosis.) 

So-called  'condensing ostitis'  or  'sclerosis'  is  in  its  results  an  hypertrophy, 
making'  the  bone  denser  and  stronger  ;  the  new  material  has  sufficient 
vitality  to  stand,  and  sufficient  blood  supply  to  support  it  as  well  as  the 
original  tissue  ;  such  a  process  we  see  in  chronic  periostitis,  the  results  of 
which  may  be  compared  with  the  sclerosed  bone  of  repaired  rickets. 

Should,  however,  this  deposit  of  new  bone  go  on  beyond  a  certain  point, 
the  blood  channels  become  themselves  so  narrowed  that  the  surrounding 
bone  is  starved,  and  so  necrosis  may  result. 

It  should  be  noticed  that  while  some  of  these  processes  of  destruction  and 
growth  and  repair  are  constantly  seen  going  on  side  by  side,  as  where  chronic 
osteomyelitis  causes  central  necrosis  and  at  the  same  time  the  periosteum 
forms  a  new  peripheral  layer  of  bone,  in  others  we  do  not  see  any  repair  so  long 
as  the  disease  is  spreading  :  thus,  in  caries  of  a  flat  bone  or  an  articular  sur- 
face, until  the  destructive  process  ceases,  no  new  bone  is,  as  a  rule,  laid  down. 

Inflammation  in  bone  may  occur  primarily  either  as  a  periostitis  or  as  an 
osteomyelitis,  the  latter,  often  called  osteitis,  attacking  the  endosteum  and 
marrow  in  the  medullary  cavity  or  in  the  cancellous  tissue.  Compact  bone 
can  hardly  be  supposed  ever  to  be  the  seat  of  a  primary  lesion,  though 
constantly  involved  by  direct  extension  along  the  Haversian  canals  from 
either  periosteum  or  medulla,  it  being  remembered  that  a  thin  layer  of  me- 
dullary tissue  lies  in  each  Haversian  canal.  Inflammation  beginning  in  the 
epiphysial  line  may  be  considered  as  an  osteomyelitis. 

Periostitis. — Acute  periostitis,  phlegmonous  periostitis,  or  'acute 
necrosis,'  is  a  disease  essentially  of  childhood  and  youth,  rare  in  infancy,' 
and  still  rarer  in  adult  life,  though  we  have  seen  it  in  a  man  of  over  fifty  and 
in  a  young  man  of  about  twenty-five.  These  are  facts  of  importance,  since 
they  show  that  the  disease  does  not  necessarily  begin  in  or  near  the 
epiphysial  line.  The  disease  is  seen  in  two  distinct  forms,  corresponding  to 
the  anatomical  structure  of  the  periosteum  ;  in  the  one  there  is  an  acute 
inflammation,  with  pouring  out  of  the  inflammatory  products  between  the 
surface  of  the  bone  and  the  deep  fibrous  layer  of  the  periosteum  (true,  deep, 
sub-periosteal  abscess)  ;  in  the  other  the  exudation  takes  place  superficially 
to  the  deep  fibrous  layer,  in  the  looser  cellular  zone  which  connects  the 
periosteum  with  the  surrounding  cellular  tissue  (parosteal  abscess).  The 
difference  in  texture  of  these  two  layers  is  of  the  utmost  importance,  and  is 
marked  by  striking  differences  in  the  course  and  results  of  the  inflamma- 
tion. While  the  sub-periosteal  effusion,  whether  serous  or  purulent,  lifts  up 
the  periosteum  from  the  bone,  presses  upon  and  detaches  the  vessels  passing 
to  the  Haversian  canals,  and  thus  cuts  off  the  blood  supply  to  the  affected 
part,  and  further,  by  the  extreme  tension  under  which  it  is  pent  in,  gives  rise 
to  all  those  evil  results  due  to  pressure  of  confined  fluid,  on  the  other  hand, 
the  supraperiosteal  exudation  lies  in  loose  tissue,  interferes  comparatively 
little  with  the  blood  supply  kO  the  bone,  and  is  not  bound  down,  so  that  there 
is  but  little  tension. 

1  W^e  have  only  twice  seen  it  under  two  years  old.  Watson  Cheyne  mentions  a  case 
of  Rosenbach's  in  which  it  occurred  in  ntero,  but  this  was  considered  to  be  an  osteo- 
myelitis (? epiphysitis). — B7-if.  Med.  Jour.  March  3,  1888. 


638  Diseases  of  the  Bones 

Either  form  of  acute  periostitis  may  be  met  with  as  a  result  of  injury, 
exposure  to  cold  and  wet,  as  a  sequel  of  one  of  the  exanthems,^  or  as  a 
pyasmic  condition.  It  will  nearly  always  be  found  that  one  of  these  causes 
has  produced,  or  at  least  preceded,  the  attack  ;  often  two  or  more  may  be 
combined.  The  disease  is  an  infective  one,  and  in  some  cases  pure  cultures 
of  staphylococci  may  be  obtained  from  the  pus. 

The  onset  of  acute  periostitis  is  marked  by  fever  with  its  general  constitu- 
tional disturbance,  rigors,  pain  in  the  affected  limb,  with  swelling  coming 
on  rapidly,  and  usually  involving  the  whole  length  of  the  affected  bone,  and 
often  the  adjacent  joints.  Mr.  Clinton  Dent  has  pointed  out  that  extension 
of  suppuration  to  the  joint  is  commoner  in  supra-  than  in  sub-periosteal 
abscess  ;  it  certainly  does,  however,  occur  in  both  forms.  The  skin  soon 
becomes  swollen,  red,  and  shining,  and  there  is  extreme  tenderness.  The 
temperature  commonly,  in  the  sub-periosteal  variety,  reaches  io3°-io5°,  and 
there  is  much  prostration.  Soon  the  swelling  increases,  and,  if  proper  treat- 
ment is  not  adopted,  in  a  few  days  pus  finds  its  way  to  the  surface  and  is 
discharged,  with  much  relief  to  the  symptoms.  Usually,  however,  fresh  foci 
of  suppuration  arise,  and,  if  the  child  is  neglected,  in  a  large  number  of 
instances  pyeemia  occurs,  and  the  patient  dies  ;  in  others,  after  much 
destruction  of  periosteum  and  the  formation  of  many  abscesses,  the  limb  is 
left  riddled  with  sinuses  leading  down  to  the  bare  dead  shaft. 

Sometimes,  but  not  commonly,  the  neighbouring  joints  suppurate  by 
direct  extension  from  periosteum  to  capsule,  and  thence  to  synovial  mem- 
brane ;  most  often,  however,  there  is  merely  a  serous  effusion,  the  result  of 
interference  with  circulation,  or  a  slight  degree  of  inflammation. 

Suppuration  of  a  joint  by  direct  extension  might  be  expected  to  be  most 
common  in  the  case  of  the  hip,  where  the  epiphysial  line  lies  within  the 
joint,  and  this  complication  does  sometimes  occur  ;  it  is  not,  however,  common 
in  our  experience.  Of  twenty-three  cases  of  acute  periostitis  under  our  care, 
the  femur  was  affected  alone  in  eight  instances,  the  tibia  was  attacked  in  six 
cases  (in  two  of  these  there  was  extension  upwards  to  the  femur),  the 
humerus  alone  in  two  cases,  the  humerus  and  ulna  in  one,  the  radius  in  one, 
the  ulna  alone  in  one,  the  fibula  in  one,  a  rib  in  one,  the  ilium  in  one,  and 
a  metatarsal  bone  in  one  instance  was  inflamed.  Five  of  these  cases  were 
supra-periosteal  (parosteal),  and  in  them  no  necrosis  followed.  There  were 
five  deaths,  all  from  pysemia,  and  all  in  sub-periosteal  cases  ;  one  child  had 
non-purulent  pericarditis  (proved  by  aspiration)  and  recovered. 

Usually  the  inflammation  is  limited  by  the  attachment  of  the  periosteum 
to  the  epiphysial  line,  and  does  not  reach  beyond  this  ;  sometimes  it  spreads 
in  along  this  line  and  loosens  the  shaft  from  its  epiphysis,  or  sets  up  an 
osteomyelitis.  The  same  endosteal  lesions  may,  of  course,  result  from  exten- 
sion inwards  along  the  Haversian  canals,  but  we  think  it  is  not  the  rule  to 
find  suppuration  within  the  medulla,  either  epiphysial  or  diaphysial,  as  the 
result  of  acute  periostitis.  Quite  apart  from  osteomyelitis,  the  whole  shaft 
may   necrose,    probably   because   not  only  is    the  blood    supply   from    the 

1  Periostitis  and  necrosis  after  typhoid  do  not  occur  till  the  patient  is  well  of  his  fever 
(Paget,  Path.  Soc.  Trans.  1884).  Macnamara,  however,  quotes  Affleck's  cases  of  peri- 
ostitis in  the  third  week  of  typhoid.  We  have  seen  a  case  of  acute  periostitis  of  the  fibula 
following  exposure  to  cold  after  influenza. 


Acute  Periostitis 


639 


numerous  small  vessels  entering  the  bone  throughout  its  length  cut  off,  but 
also  because  the  nutrient  artery  itself,  as  well  as  the  supply  from  the  epi- 
physial zone,  is  lost.^ 

Mr.  Macnamara,  Mr.  Tubby,-  and  others  believe  that  all  these  cases  really 
begin  as  an  inflammation  of  the  epiphysial  line,  and  that  the  mischief  spreads 
downwards  and  upwards,  both  beneath  the  periosteum  and  in  the  medulla. 
That  such  a  condition  does  occur  their  specimens  prove,  and  we  readily 
admit  from  our  own  experience,  but  that  it  is  by 
any  means  the  universal  condition  we  cannot 
agree. 

If  left  to  itself,  then,  and  the  patient  survives, 
acute  periostitis  results  in  necrosis  of  a  part 
or  the  whole  of  the  shaft  of  the  long  bone 
attacked  ;  subsecjuently  new  bone  is  thrown 
out  by  the  surviving  periosteum  and  surround- 
ing tissues,  and  the  sequestra  are  inclosed  in 
the  sheath  of  this  new  bone,  in  which  are 
cloaca;  leading  down  to  the  dead  part.^ 

Probably  because  the  disease  is  a  somewhat 
uncommon  one,  it  is  often  mistaken,  when  it 
does  occur,  for  erysipelas  or  rheumatism  ;  most 
of  the  cases  of  necrosis  resulting  from  it  are 
said  to  have  followed  one  or  other  of  these 
diseases.  From  erysipelas  it  is  distinguished 
by  the  much  greater  pain  in  periostitis,  by  the 
absence  of  any  defined  line  of  redness,  by  the 
limitation  of  the  disease  and  its  evident  relation 
to  the  shaft  of  a  long  bone,  and,  as  soon  as  an 
incision  is  made,  by  the  exposure  of  the  bone 
shaft. 

There -is,  of  course,  no  real  resemblance  to 
rheumatism  of  joints,  inasmuch  as  the  joints  are 
only  involved  in  very  minor  degree,  so  that  this 
is  a  less  excusable  mistake.  The  disease  most 
closely  resembling  it,  especially  the  supra- 
periosteal  form,  is  diffuse  cellulitis  ;  this,  how- 
ever, is  usually  more  superficial  and  more 
widespread,  not  ceasing  at  the  joints.  In  one 
case  which  we  saw  with  Mr.  Coates,  of  Man- 
chester, the  mischief  spread  from  tibia  to  knee,  and  beyond  this  upwards  to 
the  lower  end  of  the  femur — but  this  is  very  exceptional  ;  there  was  no 
suppuration  in  the  femur.     We  have  had  another  very  similar  case. 


Fig.  138.  —Acute  Periostitis  of  the 
Femur,  showing  stripping  off  of 
periosteum  and  separation  of  the 
epiphysial  junction.  The  lower 
part  of  the  shaft  has  been  r&- 
■moved  ^osi  mortem. 


^  Vide  Dent's  able  paper,  Med.  Chir.  Trans.  1881.  Mr.  Dent  believes  that  the 
medulla  may  disintegrate  without  being  inflamed  at  all.  Vide  also  Makins  and  Abbott, 
St.  Thomas  s  Hospital  Reports,  1889. 

-  Brit.  Med.  Jour.  May  9,  1891. 

^  Dr.  Macewen,  in  a  paper  in  the  Annals  of  Surgery ,  expresses  disbelief  in  the  existence 
of  any  bone-forming  power  in  the  periosteum,  and  believes  that  all  new  bone  is  formed 
from  bone  itself.      His  views  are,  however,  not  at  present  accepted. 


640  Diseases  of  the  Bones 

There  is  but  one  treatment  of  acute  periostitis  at  all  worthy  of  considera- 
tion, and  that  is  free  incisions  down  to  the  bone  through  the  periosteum,  as 
soon  as  the  disease  is  diagnosed  :  each  incision  should  be  about  one  inch  to 
two  inches  in  length,  and  made  in  the  long  axis  of  the  bone,  care  being  taken, 
where  practicable,  to  make  the  incisions  not  all  on  one  side  of  the  limb, 
though,  of  course,  important  vessels,  &c.  must  be  avoided.  Several  shorter 
incisions  are  better  than  one  the  whole  length  of  the  limb,  as  Mr.  Holmes 
has  pointed  out. 

"Bleeding  is  usually  very  free,  and  it  may  be  necessary  to  plug  the  wounds 
for  a  few  hours  to  arrest  it ;  the  plugs  should  then  be  removed,  drainage 
tubes  inserted,  and  the  wounds  dressed  every  day  or  two,  or  oftener  if  there 
is  much  discharge.  Should  no  pus  be  found  at  the  time  of  incision,  provided 
that  it  is  certain  that  the  bone  has  been  laid  bare,  it  may  be  taken  as  a 
proof  that  the  disease  is  in  its  early  stage,  and  the  pi^ospect  is  therefore 
better.  In  all  cases,  however,  serum  and  flakes  of  lymph  will  be  found, 
even  if  there  is  no  pus,  and  there  will  usually  be  free  suppuration  in  a  short 
time.  Too  free  exploration  of  the  bone  with  the  finger  or  probe,  and  too 
frequent  or  forcible  syringing,  are  to  be  avoided,  as  tending  to  separate  any 
still  adhering  periosteum,  or  to  prevent  adhesion  after  separation  has  oc- 
curred. The  limb  should  be  kept  slightly  raised,  and  stimulants,  opium, 
and  abundant  nourishment  given  to  the  child.  Should  the  fever  not  subside 
in  a  few  hours,  it  is  probable  that  some  abscess  has  not  been  relieved,  and  a 
director  should  be  passed  round  the  bone,  or  a  fresh  incision  made  at  any 
painful  spot.  In  the  tibia,  for  instance,  where  incisions  can  hardly  be  made 
at  the  back,  pus  may  be  lying  beneath  the  periosteum  at  the  back  of  the 
bone,  bound  down  by  muscular  attachments.  In  spite  of  the  au  hority  by 
which  it  is  supported  (Billroth),  we  cannot  regard  applications  of  nitrate  of 
silver  or  iodine,  or  anything  except  free  incision,  as  good  treatment. 

Since  such  extensive  necrosis  and  so  much  suppuration  with  liability  to 
pyccmia  often  follow  in  these  cases,  it  has  been  proposed  to  resect  the 
affected  bone  at  the  time  of  incision,  and  this  has  been  done  by  various 
surgeons.  Since  the  periosteum  is  preserved,  a  new  bone  is  developed,  and, 
it  is  said,  without  shortening  in  cases  where  a  second  bone  exists,  as  in  the  leg 
and  forearm.^  We  cannot  say  we  see  any  great  advantage  in  this  method, 
and  it  is  impossible  in  any  case  to  be  sure  how  much  of  the  bare  bone  will 
die — usually  it  is  only  a  very  small  portion  compared  with  the  part  exposed  ; 
and,  though  we  have  at  a  later  stage  removed  nearly  the  whole  of  the  shaft 
of  some  of  the  long  bones  as  sequestra,  it  is  common  to  see  quite  small 
portions  of  dead  bone  as  the  result  of  most  extensive  stripping  off  of  peri- 
osteum. We  believe  that  much  harm  is  often  done  by  the  practice,  alread}^ 
alluded  to,  of  passing  in  the  finger,  sweeping  it  all  over  the  bone,  and  then 
remarking  that  the  whole  bone  is  bare  ;  of  course  it  is,  for  the  operator  has 
just  stripped  off  the  remaining"  periosteal  attachments.  We  think,  therefore, 
that  primary  resection  of  the  diaphysis  is  not  to  be  recommended  unless  it 
is  absolutely  detached  at  each  epiphysial  junction  and  bare  of  periosteum 
throughout — a   very    rare   condition.     Neighbouring  joints  should  not   be 

1  Much  shortening  has,  however,  followed  in  some  cases  [vide  Neve,  Indian  Med. 
Gaz.  April  1884,  who  records  a  case  of  an  inch  and  a  half  shortening  after  i-emoval  of 
the  upper  half  of  the  tibia  ;  also  Holmes,  Surg.  Dis.  of  Children). 


Acute  Periostitis  641 

incised  unless  they  arc  pretty  clearly  suppurating,  i.e.  a  slight  degree  of 
efifusion  does  not  mean  suppuration.  If  the  joint  is  full  of  fluid,  and  the 
skin  over  it  is  hot  and  its  veins  turgid,  or  if  the  swelling  does  not  subside 
rapidly  after  incision  of  the  periosteum,  the  joint  should  be  opened  or,  if  in 
doubt,  aspirated  ;  if  pus  is  found,  a  free  incision  and  the  insertion  of  a 
drainage  tube  are  required. 

It  must  be  very  rarely  that  immediate  amputation  is  demanded,  even  if 
joints  are  involved  ;  if  there  is  no  pycEmia,  a  large  proportion  of  the  cases 
do  well,  and  if  pytemia  exists  already  amputation  will  not  usually  succeed. 
If  after  free  incisions  the  symptoms  do  not  subside,  and  especially  if  pus 
escapes  from  the  epiphysial  line,  there  is  probably  suppurative  osteo- 
myelitis ;  the  bone  should  then  be  exposed  and  trephined  to  give  vent  to  the 
matter. 

Those  surgeons  who  only  admit  the  osteomyelitic  origin  of  the  disease 
advocate  trephining  the  shaft  of  the  bone  close  to  the  epiphysial  junction  as 
a  drastic  measure  in  all  cases.  It  should  certainly  be  done  when  there  is 
mischief  in  the  interior  of  the  bone,  and  though  it  is  certainly  not  always 
necessary  it  is  better  in  these  cases  to  do  too  much  than  too  little. 

The  time  at  which  sequestra  may  be  expected  to  be  loose  after  the  onset 
of  the  disease  varies  with  the  size  of  the  bone  and  the  extent  of  destruction  ; 
if  the  whole  shaft  dies  the  bone  will  probably  be  loose  in  a  month  or  six 
weeks  ;  if  only  a  part  is  necrosed  it  will  vary  from  the  time  mentioned  to 
many  months,  or,  in  the  case  of  the  femur,  the  bone,  especially  if  the  lower 
end  is  affected,  may  remain  for  years  without  being  detached,  and  yet  is  so 
far  devitalised  that  it  acts  as  a  foreign  body  and  keeps  up  suppuration.  This 
especially  appHes  to  periostitis  attacking  the  popliteal  surface  of  the  femur, 
and  holds  good  of  chronic  inflammation  as  well  as  acute. 

No  absolute  rule,  then,  can  be  laid  down  as  to  the  time  at  which  sequestra 
can  be  removed  ;  the  sinuses  should  be  explored  with  a  probe  from  time  to 
time,  and  if  the  dead  part  can  be  felt  to  be  movable  it  should  be  cut  down 
upon  and  taken  away.  If  no  loose  bone  can  be  felt,  but  the  probe  passes 
down  through  cloacae  in  the  new  bone  to  a  sequestrum,  the  patient  should 
be  anaesthetised,  the  limb  rendered  bloodless,  the  sinuses  laid  open,  the 
cloaca;  enlarged,  and  the  sequestra  examined  :  any  that  are  loose  should  be 
taken  away,  and  any  distinctly  dead  but  not  loose  bone  may  be  cut  away, 
but  no  doubtful  bone  should  be  disturbed- — ^it  may  recover.  The  wounds  are 
then  plugged  with  iodoform  gauze  or  lint,  and  daily  dressed  until  they  fill  up 
or  the  sequestra  become  loose.  It  is  very  seldom  that  all  the  dead  bone  is 
removed  at  one  operation  ;  usually  small  fragments  either  come  away  of 
themselves  or  have  to  be  removed  by  later  operations.  In  cleaning  out  the 
cavities  in  which  sequestra  lie  great  care  should  be  taken  not  to  break  into 
joints  or  remove  more  new  bone  than  is  necessary.  The  delay  in  waiting 
for  the  separation  of  sequestra  is  not  wasted  time,  for  the  new  bone  is  mean- 
while consolidating,  and  the  limb  getting  stronger.  In  subsequent  dressings 
care  must  be  taken  to  keep  all  the  cavities  well  drained  and  syringed  out, 
otherwise  retention  of  discharges  a,nd  detritus  will  give  trouble.  Unnecessary 
probing  of  sinuses  is  useless  and  harmful ;  it  is  useless  to  be  constantly 
feeling  bone  to  see  whether  it  is  loose,  for  the  process  of  separation  is  a 
slow  one  ;  it  is  harmful,  because  broken  granulations  readily  absorb  septic 

T  T 


642  Diseases  of  the  Bones 

material,  while  sound  ones  are  proof  against  it — moreover,  it  needlessly 
frightens  a  child.  Where  repair  is  very  slow,  and  profuse  discharge  is 
wearing  out  the  patient,  it  may  be  necessary  to  sacrifice  doubtful  bone 
for  the  sake  of  rapid  healing,  or  in  extreme  cases,  chiefly  where  there  is 
destruction  of  a  neighbouring  joint  and  great  prostration,  even  amputation 
may  be  required. 

Case. — T.  B. ,  aged  6^  3^ears,  was  admitted  April  22,  1881.  Three  weeks  previously 
the  boy  fell  down  some  steps  and  hurt  his  forehead  and  his  shin,  but  seemed  to  get 
quite  well.  Two  days  before  admission  he  complained  of  pain  in  the  left  thigh,  but  ran 
about  as  usual.  On  the  following  morning  he  could  not  get  up,  had  pain  in  the  knee, 
and  could  not  move  the  leg  ;  he  was  delirious  during  the  night,  with  profuse  sweating. 
On  admission  he  was  pale,  dull,  and  heavy-looking  ;  respiration  48,  temperature  106°, 
pulse  156,  with  low,  muttering  delirium.  He  was  ordered  four  grains  of  quinine  and 
brandy-and-egg  mixture.  The  left  thigh  was  swollen  to  nearly  double  its  normal  size 
from  the  top  to  the  knee,  and  intensely  painful.  A  short  time  after  he  came  in,  three  free 
incisions  were  made  through  the  periosteum  down  to  the  bone  ;  much  sanious  sero-pus 
and  lymph  escaped.  The  bone  was  quite  bare.  After  the  operation  the  temperature  was 
104°,  falling  to  102 '4°.  There  was  great  prostration.  The  temperature  again  rose  to 
106 '6°  at  II  P.M.,  when  he  died. 

Post-mortem. — There  were  recent  pyasmic  abscesses  in  the  lungs,  and  the  whole 
femur  was  bare  from  the  neck  to  the  lower  epiphysis.  No  other  disease  v/as  found.  Vide 
fig.  138. 

Supra-periosteal  abscess  has  the  same  general  symptoms  as  the  more 
serious  conditions,  but  it  is  much  less  severe,  for  the  reasons  already  men- 
tioned ;  the  pain  and  fever  are  less,  though  the  swelling  is  often  as  great. 
On  cutting  into  the  abscess,  and  passing  the  finger  in,  the  bone  will  be  found 
still  covered  with  the  dense  fibrous  layer,  and  is  consequently  not  bare. 
Necrosis  seldom  follows,  or  if  it  does  it  is  limited  both  in  extent  and  depth  ; 
usually  only  a  small  scale  of  bone  comes  away.  If  this  form  of  periostitis  is, 
however,  neglected,  the  deeper  layer  may  slough,  or  the  mischief  spread 
through  it,  and  more  extensive  necrosis  may  ensue.  The  diagnosis  between 
the  two  conditions  can  generally  be  made  by  the  less  severity  of  the  symptoms 
in  the  superficial  variety. 

The  immediate  and  later  treatment  is  the  same  as  that  of  the  sub- 
periosteal form,  i.e.  free  incisions  at  first,  and  subsequent  removal  of 
sequestra,  should  any  necrosis  occur. 

Case. — Supra-Periosteal  Abscess  of  Thigh. — Mary  Ann  D.,  aged  13  years  2  months  ; 
admitted  December  24,  1882.  Three  weeks  before  admission  she  had  pain  about  the 
lower  part  of  the  leg  and  walked  lame ;  the  symptoms  increased  latterly,  and  the  left 
thigh  was  noticed  to  be  swollen  and  shining ;  she  had  been  getting  thin  and  pale  for  two 
or  three  months  previously  ;  no  injury.  On  admission  a  large  fluctuating  swelling  occu- 
pied the  anterior  and  upper  half  of  the  left  thigh,  large  veins  ramified  over  the  surface, 
there  was  a  blush  of  redness  over  it,  and  some  tenderness  and  pain  ;  an  incision  was  made 
into  the  swelling,  and  a  large  quantity  of  pus  escaped,  which  was  in  close  contact  with 
the  bone,  though  the  latter  was  doubtfully  bare ;  considerable  bleeding  took  place  into  the 
abscess  cavity,  which  stopped  after  a  free  counter-opening  and  more  perfect  drainage  were 
employed  ;  she  then  steadily  improved,  and  was  discharged  well  on  August  4.  This 
case  did  not  come  under  our  care  at  first,  and  it  was  only  at  the  second  examination  that 
we  had  an  opportunity  of  exploring  the  bone  ;  at  this  time  it  was  certainly  not  bare,  a 
thin  layer|( deeper  layer  of  periosteum)  covering  the  bone.  The  constitutional  disturbance, 
as  usually  occurs  in  the  superficial  periosteal  abscess,  was  much  less  than  in  the  sub- 
periosteal form,  and  no  necrosis  followed. 


Acute  Periostitis  643 

A  careful  watch  should  be  kept  for  the  onset  of  py;cmia  in  all  cases  of 
acute  periostitis  ;  it  appears  sometimes  exceedingly  rapidly.  Wc  have  just 
mentioned  a  case  of  acute  periostitis  of  the  femur,  which  died  with  infarcts 
in  the  lungs  and  ccchymoses  on  the  pleurae  after  an  illness  of  altogether  only 
two  days,  and  another  child  died  in  the  same  way  six  days  after  an  injury 
giving  rise  to  periostitis  of  the  fifth  metatarsal  bone. 

In  some  instances  the  periostitis  is  multiple  at  the  first  :  these  cases  are 
no  doubt  pyiT^mic,  and  sometimes  occur  after  a  primary  joint  lesion  ;  thus  we 
have  seen  acute  suppuration  in  the  ankle  followed  shortly  by  an  abscess  in 
the  wrist,  and  a  few  days  later  by  periostitis  of  the  humerus  and  ulna,  and  by 
pneumonia.  After  death  no  other  lesions  than  these  were  found.  In  another 
case,  that  of  an  infant  six  months  old,  periostitis  of  the  tibia  followed  a  suppurat- 
ing na^vus  of  the  scalp  :  the  bone  necrosed  and  gave  way,  a  fracture  result- 
ing ;  the  child  died  of  pyaemia,  sinking,  as  they  so  often  do,  quite  suddenly. 

We  have  seen  a  case  of  pyccmic  necrosis  of  the  radius  in  which  the  lesion 
was  close  above  the  lower  epiphysial  line,  but  there  was  no  shortening  of  the 
bone  four  or  five  years  after.  The  patient  was  under  the  care  of  our  friend 
Dr.  Pooley,  of  Rochdale. 

The  disease  very  rarely  attacks  any  bones  except  the  long  bones  of  the 
limbs  ;  the  tibia,  femur,  humerus,  and  ulna  we  have  seen  most  commonly 
affected — sometimes  the  whole  shaft,  in  other  instances  only  a  part,  being 
laid  bare.  Occasionally  the  short  and  flat  bones  are  attacked  [vide  T.  Jones, 
'  Diseases  of  Bones,'  p.  90).  Oven  has  recorded  a  case  of  the  os  calcis 
being  the  seat  of  the  disease ;  we  have  seen  the  ilium  and  a  metatarsal  bone 
attacked,  and  acute  periositis  of  the  skull  has  been  met  with. 

A  case  of  acute  periostitis  of  a  vertebra  is  mentioned  by  Macnamara  : 
Makins  and  Abbott  have  collected  twenty-one  cases  of  vertebral '  osteomyelitis,' 
as  they  prefer  to  call  it  ('Annals  of  Surgery,  May  1896),  and  their  article 
shows  that  any  of  the  vertebrae  may  be  attacked,  and  that  either  body  or 
laminae  or  a  transverse  process  may  become  inflamed.  There  is  the  greatest 
danger  of  extension  to  the  spinal  meninges,  and  pyaemia  is  very  common 
(sixteen  of  the  twenty-one  cases  died).  The  depth  of  the  lesion  and  the 
obsc!urity  of  the  symptoms  have  prevented  the  recognition  of  the  condition 
in  many  instances.  Free  incision  and  perhaps  removal  of  a  lamina  to  set  free 
pus  within  the  spinal  cord  may  be  required.  The  lumbar  spine  is  most 
commonly  attacked  Chipault,  '  Le  Gazettedes  Hopitaux,' December  1896. 
Abstract  in  '  Medical  Chronicle,'  June  1887.  Coutts  also  records  a  series  of 
cases. 

Case. — Necrosis  of  Rib  [trajimatic).  Empyema. — Wm.  G. ,  aged  lo  years  7  months  ; 
admitted  November  20,  1881.  Nineteen  days  before  admission  fell  widi  his  side  against 
the  kerb-stone ;  two  days  later  had  much  pain  in  the  side,  and  swelling  appeared  next 
day  ;  had  rigors,  and  was  feverish  and  vomited  on  November  28.  On  admission,  pale  ; 
some  dyspnoea,  but  not  urgent  ;  anxious  expression  ;  a  soft  fluctuating  swelling  over  the 
lower  part  of  the  left  side  of  the  chest,  rather  larger  than  the  palm  of  the  hand  ;  the  heart's 
impulse  was  two  or  three  inches  to  the  right  of  the  sternum,  and  the  whole  of  the  left 
side  of  the  chest  was  dull,  and  the  respiratory  sounds  were  distant,  though  audible;  a 
cyrtometer  tracing  showed  distinct  bulging  of  the  left  side  ;  the  abscess  was  opened  the 
same  day,  and  a  small  quantity  of  thin  pus  escaped  ;  the  pleural  cavity  was  then  opened 
and  a  pair  of  dressing  forceps  pushed  into  it  between  the  ribs  ;  a  large  quantity  of  slightly 
turbid  yellowish  fluid  was  evacuated,  the  abscess  cavity  was  clearly  quite  distinct  from  the 

T  T  2 


644 


Diseases  of  tlie  Bones 


pleura,  and  at  that  time  the  pleuritic  fluid  was  not  purulent ;  the  rib  was  bare,  but  not 
fractured  ;  a  tracheotomy  tube  was  tied  into  the  chest  and  the  wound  dressed  antiseptically. 
All  went  well,  and  on  December  3  a  vulcanite  tube  was  substituted  for  the  silver  tracheotomy 
tube.  On  the  following  day  it  was  seen  that  for  the  first  time  the  discharge  was  distinctly 
purulent,  and  it  was  considerable  in  amount ;  the  lower  half  of  the  left  chest  behind  was 
still  dull  and  tender  to  percussion,  though  in  front  the  resonance  was  good.  Up  to  this 
time  there  was  still  partial  orthopnoea  ;  a  week  later  another  abscess  behind  and  above 
the  first  opening  appeared,  and,  on  incising  it,  bare  bone  was  felt ;  the  dulness,  &c.  was 
clearino'  up.  By  the  end  of  January  1882,  the  discharge  from  the  chest  had  lessened  and 
the  dulness  nearly  disappeared.  On  February  2  an  incision  was  made  over  the  diseased 
rib,  and  about  a  third  of  it  removed ;  there  was  a  good  deal  of  new  bone  around  the 
sequestrum  ;  the  cavity  left  was  plugged  with  a  piece  of  sponge,  which  remained  in  place  till 
March  6,  when  some  of  it  was  cut  away  ;  several  bleeding  points  in  it  then  appeared,  due 
to  granulations  which  had  sprouted  into  it  and  held  it  firmly  in  position  ;  at  this  time  the 
left  base  was  normal,  except  slight  dulness.     On  March  13  antiseptics  were  discontinued  ; 

on  the  20th  more  of  the  sponge  was  cut  away,  and 
at  the  end  of  the  month  the  rest  was  removed  ; 
it  was  found  that  it  was  impeding  healing  and 
causing  eversion  of  the  edges  ;  the  sponge  was 
filled  with  granulation  tissue,  which  microscopically 
was  seen  to  penetrate  the  unaltered  sponge  frame- 
work. The  wound  rapidly  closed,  and  on  May  5 
he  was  discharged  almost  well ;  there  was  little 
if  any  retraction  of  the  side,  and  the  lung  had 
apparently  fully  expanded.  Here  traumatic  peri- 
ostitis of  the  rib  led  to  abscess  externally  and 
serous  effusion  into  the  pleural  cavity  ;  after  the 
opening  was  made  probably  the  suppuration  in 
the  chest  cavity  resulted  from  the  communication 
with  the  external  abscess. 


It  is  usually  only  in  cases  which  are  so 
severe  as  to  be  fatal  that  joint  invasion  or 
multiple  bone  lesions  are  found,  but  we 
have  met  with  an  instance  in  which  the  tibia 
was  first  attacked,  then  the  knee  joint  by 
direct  extension,  the  humerus,  lower  jaw  and 
opposite  femur  all  were  involved,  and  yet 
the  child  completely  recovered. 

Arrest  of  growth  from  destruction  or 
synostosis  of  the  epiphysial  line  may  result^  ; 
or,  on  the  other  hand,  there  may  be  over- 
growth from  persistent  hypersemia  of  the 
limb,  as  the  result  of  the  subsequent  irri- 
tation caused  by  sequestra  (fig.  139).  This 
overgrowth  may,  as  seen  in  the  figure,  cause  distortion  from  one  bone  of  the 
limb  outgrowing  the  other.^  Occasionally  relapses  occur  many  years  after 
the  original  disease  has  subsided,  and  abscesses  form,  and  sequestra  are 

1  J.  H.  Morgan  has  detailed  a  case  in  the  Brit.  Med.  Jour.,  September  i,  1883.  The 
humerus  was  the  bone  affected.      Vide  also  Tubby,  Lancet,  June  6,  1891. 

2  Birkett  has  recorded  a  case  of  overgrowth  of  a  limb  after  injury  to  the  patella  in  a 
boy  of  eight  years  [Path.  Soc.  Ti-ans.  vol.  xviii.) ;  vide  also  Edmunds,  Path.  Soc.  Ti-ans- 
1885.  A  case  of  B.  Pollard's,  described  as  hypertrophied  callus,  is  perhaps  of  the  same 
nature. 


Fig.  139. — Shows  Overgrowth  of  the 
Bones  of  the  Right  Leg,  especially 
the  Tibia,  after  Necrosis.  (Dr. 
Massiah's  case.) 


Acute  Periostitis  645 

separated  in  middle  life.     We  have  several  times  met  with  these  cases  of 
'  relapsed  necrosis.' 

Where  the  periosteum  has  extensively  sloughed,  or  where  the  bone  has 
been  fractured,  a  short,  weak  limb  may  result  from  deficient  development  of 
new  bone  ;  these  fractures  sometimes  remain  ununited,  and  may  require 
resection  and  wiring. 

Case. — Non-Union  of  Tibia  after  Fracture  as  Result  of  Necrosis. — Female,  age 
4  years  s  months  ;  five  months  ago  left  hospital,  after  sequestrotomy,  in  a  plaster  bandage  ; 
no  union  occurred,  and  limb  was  useless  and  quite  movable,  though  not  flail-like  ;  incision 
made  down  upon  ends  of  bone,  which  were  much  atrophied  :  surfaces  refreshed  and  wired 
together  by  one  silver  suture,  which  was  fixed  to  buttons  on  surface  of  wound  ;  ultimately 
firm  union  occurred,  and  child  could  bear  her  weight  upon  her  leg  and  walk  well. 

As  the  accounts  of  different  writers  on  the  subject  of  acute  bone  inflamma- 
tion are  somewhat  conflicting,  and  give  rise  to  confusion,  the  following 
statement  of  how  the  different  lesions  may  arise  will  perhaps  be  of  ser\ice 
to  those  less  familiar  with  bone  diseases. 

Acute  inflammation  of  bone  may  begin  as  : 

A.  Periostitis. 

r.  Sub-periosteal. 

2.   Supra-periosteal  or  Parosteal. 

B.  Osteomyelitis. 

1.  Epiphysitis,  i.e.  disease  beginning  in  the  cancellous  tissue  of  the 

epiphysis. 

2.  Inflammation  of  the  medulla  of  the  shaft  (diaphysitis). 

3.  Inflammation    beginning   in    the    epiphysial  line,    often  called 

epiphysitis  also. 

4.  '  Juxta  epiphysary  diaphysitis,'  or  inflammation  of  the  end  of  the 

diaphysis  close  to  the  epiphysial  cartilage. 

Inflammation  arising  in  any  of  these  ways  may  give  rise  to  the  other 
forms  of  lesion  ;  e.g.  sub-periosteal  abscess  may  spread  along  the  epiphysial 
line  and  cause  suppuration  in  the  medulla  of  the  shaft,  or  inflammation  of 
the  medulla  may  spread  outwards  and  cause  periostitis.  As  a  rule,  however, 
careful  clinical  observation  will  enable  an  accurate  opinion  to  be  given  of 
the  primary  seat  of  the  mischief.  We  are  becoming  strongly  of  opinion 
that  it  is  common  for  tuberculosis  to  be  grafted  on  to  cases  of  acute  inflamma- 
tion of  bone,  i.e.  we  believe  that  many  of  these  cases  which  after  the  acute 
symptoms  have  subsided  run  a  chronic  course,  are  really  tubercular,  and  it  is 
possible  that  in  some  at  least  the  process  may  have  been  acute  tuberculosis, 
or  at  least  a  mixed  infection  from  the  first. 

Acute  Osteomyelitis. — Acute  diffuse  infective  osteomyelitis  occurs 
as  a  result  of  amputations  or  resections,  but  this  is  a  rare  condition  ;  it  is 
said  to  be  more  common  in  hot  climates.  The  disease  is,  however,  here 
most  often  met  with  as  a  result  of  extension  to  the  medulla  of  inflammation 
beginning  in  the  epiphysis  or  epiphysial  line  or  end  of  the  diaphysis,  or  of  acute 
periostitis,  and  occasionally  occurs  as  a  primary  condition.  Mr.  Macnamara, 
and  with  him  some  of  the  continental  surgeons  as  already  mentioned, 
believe  that  the  affection  already  described  as  acute  periostitis  is  really  acute 
osteomyelitis  ;  this,  however,  is,  not  always  the  case,  since  if  it  were  so  com- 
plete recovery  in  these  cases  without  extensive  necrosis  would  not  be  nearly 


646  Diseases  of  the  Bones 

so  common  as  it  is.  Moreover,  in  cases  of  acute  periostitis  dying  of  pysemia, 
sections  of  the  bone  have  shown  an  entire  absence  of  osteomyehtis  in  some 
instances. 

The  characteristic  symptoms,  in  a  case  where  acute  osteomyehtis  fohows 
amputation,  are  sweUing  and  subsequent  suppuration  of  the  medulla,  retrac- 
tion of  the  periosteum  and  soft  parts,  so  that  the  bone  is  left  bare,  and 
diffuse  swelling  of  the  limb.  Pysemia  usually  rapidly  ensues,  and  in  many 
cases  death  speedily  results.  Amputation  at  the  joint  above  has  been 
usually  said  to  be  the  only  successful  method  of  treatment,  but  the  plan 
introduced  of  scraping  out  the  entire  contents  of  the  medullary  canal,  as 
advocated  by  Mr.  Keetley  and  others,  is  well  worthy  of  adoption,  and  has 
proved  successful  in  several  instances  ;  our  colleague,  Mr.  T.  Jones,  among 
others,  has  had  good  results  from  this  method. 

Where  acute  diffuse  osteomyelitis  occurs  as  a  sequel  to  epiphysitis  or 
periostitis,  or  is  the  primary  lesion,  the  shaft  of  the  affected  bone  should  be 
freely  opened  with  trephine  or  chisel,  and  a  similar  treatment  adopted.  The 
existence  of  this  disease  may  be  suspected  as  already  pointed  out,  when  the 
severe  constitutional  symptoms  and  pain  do  not  subside  after  freely  incising 
the  periosteum  or  opening  up  an  epiphysial  abscess  ;  swelling  and  tenderness 
at  one  or  more  points  in  the  shaft,  or  diffuse  bony  swelling  without  any  col- 
lection of  fluid  beneath  the  periosteum,  will  indicate  the  presence  of  pus  in 
the  medulla.  For  an  excellent  account  of  the  whole  ciuestion,  vide  '  Diseases 
of  the  Bones/  by  T.  Jones,  1887. 

ikcute  Epiphysitis. — Acute  circumscribed  osteomyelitis  or  acute  epiphy- 
sitis is  a  more  common  condition  ;  it  consists  in  a  localised  inflammation 
attacking  the  cancellous  tissue  of  an  epiphysis  or  the  immediate  neighbour- 
hood of  the  epiphysial  line.  The  disease  nearly  always  goes  on  to  suppura- 
tion, and  on  examination  a  cavity  will  be  found  containing  pus,  or  in  some 
cases  sequestra.  Acute  epiphysitis  may  occur  in  children  of  any  age  :  for 
instance,  most  cases  of '  acute  suppurative  arthritis  of  infants '  are  typical 
examples  of  this  disease  (vide  p.  670)  ;  in  other,  though  much  rarer,  instances 
older  children  are  attacked.^ 

If  left  to  itself,  the  pus  finds  its  way  either  into  the  adjacent  joint  or  along 
the  epiphysial  line  to  the  surface  (the  epiphysis  may  in  this  way  become 
detached  from  the  shaft),  or  down  the  medulla  of  the  shaft,  giving  rise  to 
acute  diffuse  osteomyelitis.  The  disease  may  follow  an  injury  or  exposure,  or 
one  of  the  exanthems,  or,  according  to  Mr.  Greig  Smith,  may  arise  from 
lymphatic  infection  of  the  bone  marrow.  It  most  commonly  attacks  the 
head  of  the  femur,  the  upper  end  of  the  tibia,  or  the  lower  end  of  the  femur, 
less  often  the  extremities  of  other  long  bones.  Some  of  the  cases  of  acute 
disease  of  the  hip,  elbow,  shoulder,  and  ankle,  apart  from  '  acute  suppurative 
arthritis  of  infants,'  are  really  also  of  this  nature. 

The  lesion  is  marked  by  early  fever  and  much  pain,-  of  gnawing,  tooth- 
ache-like character,  followed,  after  a  longer  or  shorter  time,  according  to 
the  age  of  the  patient  and  the  amount  of  resistance  to  the  exit  of  the  pus, 
by  swelling  of  the  bone  coverings  and  effusion  into  the  adjacent  joint,  which 

"•  Vide  Abstracts  of  Cases  treated  at  Childreiis  Hospital,  Pendlebury,  1882. 
-  In  the  infantile  cases  we  have,  of  course,  no  means  of  knowing  the  kind  of  pain,  but 
usually  it  is  evidently  severe. 


Acntc  Epiphysitis  647 

is  usually  kept  fixed  in  the  position  of  least  tension.  We  have,  however, 
seen  the  knee  strained  to  its  utmost  degree  of  flexion,  far  beyond  the  point 
of  least  tension  ;  thus  showing  at  once  that  the  lesion  could  not  be  intra- 
articular. 

The  pain  is  usually  agonising,  and  the  failure  of  health  very  rapid.  Deep 
pressure  in  the  earlier  stages,  and  any  touch  of  the  limb  when  the  pus  is 
approaching  the  surface,  is  exceedingly  painful.  Local  heat  is  usually  only 
appreciable  in  the  later  stages  ;  increased  pulsation  in  the  main  artery  of  the 
limb  may  be  found.  In  infantile  arthritis  (acute  suppurative  arthritis)  the 
symptoms  are  sometimes  subacute.  The  diagnosis  is  made  by  careful 
exclusion  of  joint  lesions  (by  lack  of  marked  effusion,  &c.),  where  the  joint  is 
still  free,  and  attention  to  the  history  of  the  pain  and  swelling,  so  as  to  dis- 
tinguish the  case  from  periostitis,  though,  of  course  as  pointed  out  by 
Macnamara  and  others,  and  as  already  described,  epiphysitis  may  give  rise 
to  sub-periosteal  abscess  and  necrosis  as  well  as  to  intra-articular  abscess  ; 
pain  on  deep  pressure  in  the  absence  of  joint  disease  is  a  characteristic 
feature.  Rheumatism  and  rickety  pain  are  readily  distinguished  by  the 
strict  localisation  of  the  suffering.  In  the  infantile  cases  the  joint  is  usually 
involved  by  the  time  the  child  is  brought. 

Case. — Abscess  in  the  Head  of  the  Tibia. — Wm.  Hy.  D. ,  age  9  j'ears  ;  admitted 
December  30,  i88t.  Had  pain  in  the  leg  for  two  months  ;  worse  for  five  days  ;  no  fur- 
ther history.  On  admission  he  was  pale,  ill,  and  anxious.  Temperature  103 •8°  ;  there 
was  intense  pain  in  the  right  knee,  which  was  flexed  to  its  fullest  extent ;  there  was  no 
effusion  in  the  joint,  and  the  outlines  of  the  condyles  were  distinct  through  the  tightly 
stretched  skin.  Over  the  head  of  the  tibia  and  the  upper  third  of  the  leg  there  was  con- 
siderable swelling,  most  marked  over  the  inner  tuberosity  of  the  tibia,  where  also  the 
tenderness  was  greatest ;  no  fluctuation  ;  under  chloroform  an  incision  was  made  over  the 
inner  tuberosity,  and  the  soft  parts  found  infiltrated  with  inflammatory  products,  but  no 
pus ;  a  chink  indicating  the  line  of  imion  of  epiphysis  and  diaphysis  was  seen,  and  on 
gouging  away  some  bone  about  5  ss.  of  thick  sanious  pus  escaped  ;  no  distinct  cavity 
was  found  ;  operation  antiseptic  ;  a  tube  was  put  into  the  opening  in  the  bone  ;  one  hour 
after  the  temperature  was  102 '6".  He  had  pain  on  several  evenings  subsequently,  and 
there  was  but  little  non-purulent  discharge  for  two  days,  when  several  drachms  of  pus  were 
discharged.  On  January  5,  as  the  joint  was  swollen,  it  was  aspirated,  and  a  small  quan- 
tity of  turbid  sanious  fluid  withdrawn  and  an  ice  bag  applied  ;  he  had  no  pain  afterwards, 
but  on  the  12th  the  joint  began  again  to  swell,  and  on  the  15th  was  distended,  and  in- 
cisions were  made  into  it,  discharging  fluid,  at  first  flaky,  but  serous,  and  subsequently 
more  nearly  purulent.  On  February  9  the  drainage  tubes  were  removed  and  all  was  going 
on  well,  the  wounds  in  the  joint  being  superficial,  though  bone  could  be  felt  through  the 
opening  into  the  tibia  ;  the  limb  had  been  kept  fixed.  On  the  23rd  the  joint  was  forcibly 
flexed  and  several  adhesions  broken  down ;  considerable  swelling  followed ;  the  joint 
shortly  settled  down  again.  March  3,  a  small  sequestrum  was  removed  from  the  tibia  as 
well  as  a  good  deal  of  caseous  material.  April  3,  the  limb  was  put  up  in  plaster  of  Paris, 
and  the  boy  sent  out  on  the  5th.  He  attended  as  an  out-patient  subsequently  ;  several 
small  bits  of  bone  came  away,  but  the  wound  finally  closed,  and  he  has  now,  February 
1883,  a  sound  limb  with  a  fully  movable  knee,  though  a  little  thickening  still  remains. 

The  treatment  of  acute  epiphysitis  consists  in  early  and  free  incision 
down  to  the  bone  ;  if  matter  is  met  with,  this  is  usually  sufficient,  but,  should 
the  pus  not  have  reached  the  surface,  an  opening  must  be  at  once  made  into 
the  bone  and  the  abscess  emptied,  any  sequestra  found  being  removed.  In 
any  doubtful  case  it  is  far  better  to  explore  the  bone  than  to  run  the  risk  of 
the  abscess  bursting  into  the  adjacent  joint.     Should  the  joint   be  already 


64  S  Diseases  of  the  Bones 

involved,  as  it  almost  always  is  in  the  acute  epiphysitis  of  infants,  it  must  be 
freely  opened  and  drained.  For  a  more  detailed  account  of  infantile  epiphy- 
sitis, see  the  chapter  on  Diseases  of  the  Joints,  p.  670.  Messrs.  Pick 
and  Page  have  recently  called  attention  again  to  these  cases  which  have 
been  described  above,  and  discussed  both  in  former  editions  of  this  book 
and  elsewhere. 

Should  the  mischief  have  spread  to  the  medulla  of  the  shaft,  the  diaphysis 
should  be  exposed  and  trephined  at  one  or  more  spots  to  give  vent  to  the 
pus,  and  the  whole  medullary  cavity  should  be  scraped  out,  washed,  and 
drained  ;  failing  this,  amputation  is  the  last  resource.  For  some  good  cases 
illustrating  this  treatment,  vide  T.  Jones  on  '  Diseases  of  the  Bones,'  1887, 
and  'Medical  Chronicle,'  Dec.  1886. 

A  condition  known  as  '  Growing  Pever '  is  sometimes  met  with,  usually 
in  children  of  from  seven  to  fifteen  years,  though  occasionally  at  both  earlier 
and  later  ages.  The  main  features  are  pain  in  the  region  of  the  epiphysial 
lines,  rapid  growth  and  som.etimes  fever,  with  considerable  constitutional 
disturbance.  Usually  the  symptoms  pass  off  without  any  bad  result,  but  in 
rare  cases  osteomyelitis  may  be  set.  up,  and  the  development  of  exostoses 
about  the  epiphysial  lines  has  also  been  noticed  after  the  occur- 
rence of  'growing  fever'  {vide  'British  Medical  Journal,'  April  14,  1888, 
p.  820). 

Chronic  Periostitis. — Periostitis  of  less  severity,  and  less  rapid  in  pro- 
gress, is  common  enough,  and  the  subacute  cases  are  better  classed  with  the 
chronic  than  with  the  acute,  inasmuch  as  they  are  more  like  the  former 
than  the  latter  in  their  results.  Subacute  or  chronic  periostitis  occurs  in 
children  as  the  result  of  injury,  as  a  pysemic  condition,  or  as  the  sequela  of 
an  exanthem — probably  these  two  sets  of  cases  are  very  closely  allied,  if  not 
identical  ;  or  it  may  be  caused  by  syphilis  or  tubercle.  Whichever  of  these 
is  the  cause  in  any  individual  case,  suppuration  often  takes  place  except  in 
traumatic  and  in  many  of  the  syphilitic  cases.  Since  the  process  is  a  slow 
one,  it  is  usually  impossible  to  say  whether  the  lesion  began  as  a  sub-  or 
supra-periosteal  inflammation  ;  perhaps  the  whole  thickness  of  the  membrane 
is  involved  at  once,  or  else,  as  the  bone  is  usually  more  or  less  deeply  impli- 
cated, the  lesion  is  sub-periosteal  in  origin. 

The  disease  is  characterised  by  local  or  diffused  thickening  of  the  bone 
in  its  early  stages  ;  the  swelling  is  tender,  painful  at  times,  but  usually,  unless 
in  subacute  cases,  there  is  no  implication  of  the  skin.  Later  on,  the  swelling, 
if  left  to  itself,  either  subsides  or  softens  down,  and  abscesses  form  in  one  or 
more  spots  :  on  incising  these  the  bone  is  found  bare  and  rough,  with  perhaps 
small  scale-like  exfoliations,  or  in  other  cases,  to  be  described  presently, 
more  extensive  lesions.  The  periosteum  is  sometimes  four  or  five  times  its 
usual  thickness,  and  readily  peels  off  the  bone,  while  in  old  cases  there  is 
often  some  rough  spiny  deposit  of  new  bone  developed  around  the  centre  of 
disease.  In  traumatic  cases  in  healthy  subjects  the  thickening  may  subside 
altogether  without  any  trouble  or  suppuration,  or  there  may  be  sufficient  new 
bone  formation  to  cause  swelling  lasting  for  months  or  years  without  any 
other  symptoms. 

In  tuberculous  children  the  swelling  ('  strumous  periosteal  node')  usually 
slowly  increases,  often  painlessly,  though  by  no  means  always  so  ;  suppura- 


Chronic  Periostitis 


649 


tion  finally  occurs  and  matter  is  discharged,  or  in  rarer  instances  the  in- 
flammation subsides.  Generally  in  the  tuberculous  cases  periostitis  is  either 
the  result  of,  or  itself  leads  on  to,  osteomyelitis.  (Superficial  or  central 
caries.) 

Exanthematous  periostitis  is  found  usually  in  wasted  and  feeble  children, 
either  in  the  course  of,  or  as  a  sequel  to,  one  of  the  specific  fevers  ;  there  is 
often  much  suppuration,  with  but  little  pain  or  disturbance,  and  a  limb  is 
found  occasionally  to  be  little  more  than  a  flabby  bag  of  pus,  without  any  pain 
and  without  much  fever.  The  child  lies  wasted  and  haggard,  with  rough  scaly 
skin,  and  offensive  smell,  the  hair  harsh  and  often  thin,  and  the  veins  showing 
distinctly  through  the  thin,  fatless 
skin.  The  chronic  pyaemic  cases  so 
exactly  resemble  these  that  it  is 
probable  that  many  of  the  exan- 
thematous forms  are  really  pysemic. 
A  fair  number  of  such  children 
recover,  others  gradually  sink  of 
exhaustion  or  some  intercurrent 
pneumonia  or  diarrha^a.  Much 
less  severe  cases  are  also  met  with, 
in  which  chronic  periostitis  occurs 
aftecting  only  a  small  part  of  a  bone 
— it  may  be  any  bone — and  either 
subsiding  or  giving  rise  to  only  local 
necrosis  ;  the  ribs  and  tibite  and 
upper  end  of  the  femur  seem  to 
be  specially  often  attacked  after 
typhoid  fever.  For  an  excellent 
account  of  these  diseases,  vide  T. 
Jones  on  '.Diseases  of  the  Bones,' 
1 887,  p.  40  ;  vide  also  chapter  on 
Spinal  Disease,  z'^/ra,  p.  713,  for 
a  case  of  necrosis  of  a  spinous 
process. 

Congenital  syphilitic  periostitis 
is  usually  multiple,  and  occurs 
rarely  during  the  first  year  or  two 
of    life,    being    commonest     from 

about  the  5th  to  the  15th  year.  It  is,  as  Hutchinson  has  pointed  out,  less 
amenable  to  antisyphihtic  treatment  than  the  periostitis  of  acquired  syphiHs, 
and  according  to  him  is  common  in  the  upper  limbs  ;  in  our  experience 
symmetrical  periostitis  of  the  shafts  of  the  tibiae  ('  syphilitic  nodes ')  is  far 
the  commonest  form,  and  in  some  cases  it  breaks  down  and  large  ulcers 
form  on  the  surface.  The  amount  of  thickening  may  be  enormous,  as  in 
fig.  140. 

Case. — Chronic  Syphilitic  Periostitis  of  Tiiii a.— Lilian  G.,  age  12  years;  admitted 
November  19,  1884.  Mother  had  three  miscarriages  as  the  result  of  her  three  first  preg- 
nancies. Patient  when  born  had  an  eruption  about  the  buttocks,  sores  round  the  mouth, 
and  snuffles  ;  improved  at  six  months  old,  and  has  gone  on  well  since,  except  for  a  sore 


Fig.  140. — Congenital  Sj'philitic  Disease  of  both 
Tibiae  (periosteal  and  endosteal).  This  figure, 
from  a  patient  of  our  own,  is  reproduced  from 
Mr.  Jones's  book. 


650  Diseases  of  the  Bones 

eye.  Duration,  three  years  ;  following  a  slight  kick  ;  no  swelling  till  a  month  later  ;  much 
pain  ever  since  ;  has  been  under  treatment  (antis3'philitic)  as  an  out-patient  for  some  con- 
siderable time.  On  admission,  healthy-looking  girl  ;  teeth  normal  ;  no  obvious  signs  of 
syphilis  ;  the  right  tibia  is  much  thickened,  and  apparently  bowed  antero-posteriorly  ;  no 
fluctuation  ;  the  most  tender  spot  is  on  the  front  of  the  lower  part  of  the  middle  third  ;  the 
swelling  involves  nearly  the  whole  shaft ;  no  fever.  November  27,  tibia  trephined  at  its 
most  painful  spot ;  periosteum  much  thickened  ;  the  bone  was  much  sclerosed  and  the 
medullary  cavity  reduced  to  a  narrow  channel ;  no  pus  and  no  cavity  found.  The  reflected 
periosteum  was  stitched  together  with  catgut  and  tube  inserted.  Operation  antiseptic. 
All  went  well  ;  she  was  discharged  on  December  17  ;  there  was  no  further  pain,  and  when 
seen  as  an  out-patient,  February  1885,  she  was  sound  and  well,  and  free  from  pain. 

Case. — Syphilitic  Periostitis  of  Tibia. — John  Wm.  A.,  age  6  years.  No  tubercular 
history  ;  one  of  the  children  died  of  convulsions  at  seven  weeks — it  had  snuffles  ;  three 
other  children  living ;  no  miscarriages.  Child  healthy  at  birth,  weakly  since  three 
years  old ;  the  leg  has  been  tender  for  six  months,  but  no  swelling  was  noticed  till 
four  days  ago  ;  no  pain  unless  touched.  On  admission,  pale,  unhealthy  child ;  has 
remains  of  double  interstitial  keratitis  and  scars  at  the  angle  of  the  mouth  ;  the  upper 
milk  incisors  have  gone,  lower  incisors  small  and  ill-formed ;  there  is  thickening,  forming 
a  prominent  swelling  in  the  middle  of  both  tibise,  tender  but  not  red.  The  tenderness 
disappeared  quickly  under  treatment  (antisyphilitic),  the  swelling  remaining  much  the 
same. 

Less  frequently  the  upper  end  of  the  tibia  is  involved  ;  in  such  cases 
there  is  not  rarely  effusion  into  the  knee,  not  merely  passive,  but  an  actual 
serous  synovitis.     Other  evidence  of  congenital  syphilis  is  in  our  experience 
almost   always    to  be  found,  though  it  is  not  always    obvious.     One  tibia 
alone  may  be  affected  and  the  disease  may  be  progressive  in  later  life  though 
due  to  congenital  syphilis.     Occasionally  the  evidence  of  syphilis  may  be 
wanting.     The  pain  is  often  severe,  though  sometimes  it  is  almost  absent.' 
Macnamara  believes  that  the  syphilitic  telostitis  of  infants  (see  chapter  on 
Congenital  Syphilis)  is    due  to  interference  with  nutrition  at  the   epi- 
physial line  from  pressure  of  new-formed  periosteal  deposit  around,  and  that 
the  telostitis  is  not  inflammatory.-     Arrest  of  growth  may  result  just  as  in 
the  case  of  older  children  who  are  attacked  by  syphilitic  epiphysitis^  {vide 
Epiphysitis).   The  palate  and  bones  of  the  face  are  not  rarely  destroyed  by 
congenital    syphilis,    but  this  occurs  in  a  late  stage   of  the   disease   {vide 
fig.  91)  ;  the  nasal  bones  are,  of  course,  early  affected,  and  the  deformity 
resulting  gives  rise  to  one  of  the  characteristic  features  of  inherited  syphilis. 
The  evidence  afforded  by  thickening  of  the  bone,  with  tenderness  on  deep 
pressure  and  aching  pain,  serves  to  distinguish  periostitis  generally  from 
any  more  superficial  lesion,  while  the  onset  of  swelling  and  pain    simul- 
taneously points   to  the   existence  of  periostitis   rather  than  osteomyelitis, 
though  either,  it  must  be  remembered,  may  give  rise  to  the  other.     New 
growths  are  to  be  distinguished  by  their  greater  rarity,  their  greater  promi- 
nence, with  often  bosses  and  a  well-defined  margin,  and  local  patches  of 
softening,  as  well  as  by  their  situation,  which  is  usu.ally  at  the  ends  of  the 
bones  ;  hence  they  are  more  likely  to  be  mistaken  for  osteomyelitis  than  for 
periostitis. 

The  tuberculous  and  syphilitic  lesions  are  nearly  always  accompanied  by 

1  Mr.  Moullin  has  written  a  good  paper  on  this  subject  in  the  Brit.  Med.  Jour.  1884,  p.  52. 
-  Brit.  Med.  Jour.  Julys,  1884.         ^  Hutchinson,  London  Hospital  Reports,  vol.  ii. 


Chronic  Periostitis  651 

other  evidences  of  their  respective  diseases,  such  as  tuberculous  glands  or 
ulcers,  a  family  history  of  tubercle,  or,  on  the  other  hand,  syphilitic  lesions 
of  the  eyes,  teeth,  &c.' 

There  is  difficulty  sometimes  in  distinguishing  the  lesions  of  bone  due 
to  congenital  syphilis  from  those  dependent  upon  tuberculosis,  though  we 
are  not  inclined  to  think  that  the  mistake  is  so  often  made  as  Fournier- 
would  have  us  suppose.  As  already  mentioned,  the  tibia  is  (as  Fournier 
also  points  out)  the  bone  most  commonly  affected  by  the  syphilitic  lesions, 
and  the  long  bones  are  more  often  attacked  than  the  short  or  flat  bones, 
with,  perhaps,  the  exception  of  the  skull,  while  the  diaphysis  is  more  liable 
to  be  attacked  by  syphilis  than  the  epiphyses.  New  bone  formation,  severe 
pain,  little  tendency  to  suppuration,  though  occasionally  abscess  and 
necrosis  do  occur,  and  evidences  of  syphilis  from  the  history  or  presence  of 
other  syphilitic  lesions,  are  the  principal  features  of  the  one  group,  while 
the  tuberculous  cases  are  characterised  by  absence  of  any  new  bone  forma- 
tion, caries  occurring  rather  than  necrosis,  by  early  suppuration,  freedom 
from  pain,  and  the  other  features  already  pointed  out.  The  effects  of  treat- 
ment by  iodide  of  potassium  will  give  confirmatory  evidence.  In  any  case 
of  doubt  antisyphilitic  treatment  should  be  given  a  fair  trial,  it  being 
remembered  that  children  bear,  and  often  require,  large  doses  of  iodide 
(gr.  x.-xx.)  to  obtain  good  results.  It  must  not  be  forgotten  that  congenital 
syphilitic  lesions  may  co-exist  with  tuberculous  disease,  and  in  such  cases 
affections  apparently  tuberculous  will  not  yield  until  antisyphilitic  treatment 
is  employed. 

Nearly  all  the  varieties  of  periostitis  are  found  chiefly  in  the  long 
bones,  though  similar  lesions  may  be  met  with  elsewhere,  as  in  the  jaws, 
&c.  ;  vide  chapter  on  DISEASES  OF  THE  MoUTH,  and  also  the  chapter  on 
Joints. 

Treat))ie)it. — In  early  stages  of  the  disease,  if  the  leg  is  affected  the  child 
should  be  kept  in  bed  with  a  splint  on.  Cod  liver  oil  and  iron  should  be 
gi\en  in  the  tuberculous,  hydrarg.  c.  creta  or  iodide  of  potassium  in  the 
syphilitic  cases  ;  the  former  in  children  one  or  two  years  old,  and  a  com- 
bination of  the  mercury  and  iodide  in  older  cases  being  the  best  treatment. 
Where  the  arm  is  affected,  a  splint  should  be  applied  and  the  child  allowed 
to  be  up,  unless  any  subacute  mischief  is  going  on.  Simple  traumatic  cases 
recjuire  rest  and  the  application  of  soothing  lotions,  such  as  lead,  with  or 
without  spirit  or  opium,  or  the  application  of  belladonna  diluted  with  glycerine 
or  vaseline  ;  in  some  cases  good  is  done  by  rubbing  in  mercurial  ointment, 
or  better,  ung.  hydrarg.  oleat.  5  or  10  per  ct.,  or  keeping  it  applied  over  the 
swelling.  Some  surgeons  have  faith  in  the  application  of  iodine  ;  a  blister 
is  sometimes  undoubtedly  of  use  in  relieving  pain.  If  after  a  fair  trial  of 
some  weeks  no  good  result  has  been  obtained  by  these  means,  and  pain 
still  persists,  or,  of  course,  earlier  than  this  if  suppuration  occurs,  an  incision 

1  Dr.  Goodhart  has  met  with  a  remarkable  case  of  bone  disease  in  a  child  a  year  old, 
which  was  thought  to  bear  relation  to  osteitis  deformans,  but  was  probably  syphilitic  ; 
there  were  tenderness,  softening,  and  diffused  thickening  of  the  bone  ;  rickets  co-existed. — 
Path.  Soc.  Trans,  vol.  xxxiv. 

-  La  Syphilis  Hdreditaire  Tardive.  Paris,  1886.  To  this  work  we  must  refer  for  an 
elaborate  account  of  the  later  lesions  of  hereditary  syphilis. 


652  Diseases  of  the  Bones 

should  be  made  down  upon  the  bone  through  the  periosteum  ;  if  pus  is 
found,  or  any  superficial  necrosis,  the  case  is  to  be  treated  on  ordinary 
principles  ;  if  after  this  the  pain  is  not  relieved  or  returns,  it  may  be  taken 
for  certain  that  osteomyelitis  exists,  either  as  a  primary  or  secondary  con- 
dition ;  and  this  should  specially  be  borne  in  mind  in  tuberculous  cases  in 
which  osteomyelitis  is  much  more  commonly  the  primaiy  lesion  in  long 
bones.  If  then  there  is  evidence  of  osteomyelitis,  further  measures  will  be 
required  {%iide  infra). 

Occasionally  in  syphilitic  cases  no  absorption  takes  place  under  mercurial 
or  iodide  treatment  ;  if  the  pam  persists,  the  bone  should  be  cut  down  upon 
and,  if  necessary,  trephined  or  gouged,  so  as  to  open  up  the  sclerosed  bone 
and  give  vent  to  any  pent-up  material  (cf  case,  p.  649,  antea).  In  cases  of 
syphilitic  necrosis  of  the  bones  of  the  face  or  palate  a  plastic  operation  may 
be  required,  but  this  should  not  be  attempted  until  the  destructive  process 
has  entirely  ceased.  Where  the  whole  hard  palate  has  been  destroyed  an 
obturator  may  be  necessary.  We  have  seen  a  case  where,  after  ulceration 
of  the  palate  and  pharynx,  the  soft  palate  became  adherent  to  the  pharyngeal 
wall,  and  the  obstruction  to  the  nose  thus  produced  caused  so  much  trouble 
that  excision  of  part  of  the  soft  palate  became  necessary.  '  Periostitis 
albuminosa'  is  a  name  given  to  a  form  of  periostitis  in  which  there  is 
effusion  of  non-purulent  fluid  beneath  the  periosteum.  There  may  or  may 
not  be  necrosis.  There  is  no  hard-and-fast  line  to  be  drawn  between  these 
cases  and  chronic  purulent  periostitis  ;  the  exact  nature  of  the  effusion  may 
in  our  experience  vary  from  serum  to  solid  lymph  on  the  one  hand  or  pus 
on  the  other  ;  a  similar  variation  occurs  in  the  case  of  the  effusion  in  central 
inflammation.  We  have  found  the  medulla  replaced  by  masses  of  curd-like 
lymph  with  little  or  no  pus. 

Chronic  Circumscribed  Osteomyelitis. — Where  chronic  osteomyelitis 
is  localised,  as,  for  instance,  sometimes  in  the  epiphysial  extremities  of  the 
long  bones,  an  abscess  may  result,  with  or  without  necrosis  ;  the  symptoms 
are  those  of  acute  epiphysitis,  already  described,  only  less  severe,  and  the 
onset  of  the  disease  is  slower  and  more  insidious.  In  non-tuberculous  cases 
there  is  often  much  sclerosis  of  bone  around  the  abscess  cavity,  and  the 
disease  may  go  on  for  years  without  any  attempt  at  reaching  the  surface. 
In  other  instances  the  extension  of  the  inflammation  to  the  surface  is  marked 
by  slight  and  slowly  increasing  thickening  of  the  periosteum,  so  that  the 
diameter  of  the  bone  is  somewhat  increased,  and  the  tissues  over  it  may  be 
slightly  osdematous.  The  characteristic  aching,  gnawing  pain,  especially  at 
night,  is  sometimes  well  marked,  but  in  children  more  often  there  is  com- 
paratively little  pain,  and  the  pus  soon  finds  its  way  to  the  surface — both 
these  facts  being  due,  no  doubt,  to  the  less  resisting  nature  of  the  softer 
bones  of  children.  Hence  the  more  typical  features  of  chronic  circumscribed 
abscess  of  bone  are  comparatively  seldom  seen  in  young  children,  but  are 
most  marked  in  young  adults.  Moreover,  in  children  the  distinction  between 
circumscribed  and  diffuse  osteomyelitis  is  also  less  defined  ;  though  sclerosis 
of  the  walls  of  the  cavity  does  sometimes  occur,  it  is  less  frequent  in  children, 
and  the  inflammation  is  more  apt  to  become  diffuse.  The  attacks  of  pain 
may  be  intermittent,  so  that  for  weeks  or  months  there  is  little  sign  of  any- 
thing wrong,  and  then  all  the  symptoms  reappear. 


Chronic  Circumscribed  Osteomyelitis 


653 


Cask. — Epiphysitis  of  liot/i  Femora,  5fc. — John  \\'.,  age  6;  admitted  April  12,  1884. 
Always  delicate  ;  for  eighteen  months  past  had  abscesses  ;  twelve  months  ago  had  dropsy  ; 
eight  months  ago  had  measles  ;  four  months  ago  knee  swelled  painlessly,  was  poulticed 
and  opened.  On  admission,  delicate  child  ;  abscess  scars  about  neck,  &c.  Sinus  over 
left  upper  arm  leading  to  bare  bone.  Just  above  right  knee  is  a  sinus,  and  two  more  in 
popliteal  space,  another  below  the  knee  ;  at  lower  third  of  leg  is  a  large  abscess  ;  sinuses 
also  round  left  knee.  i8th,  abscesses  on  leg  and  knee  opened  ;  21st,  sent  out  for  a 
while.  Readmitted  May  19.  June  3,  explored,  and  bare  bone  felt  at  back  of  right  knee 
and  in  arm.  June  11,  under  chloroform.  Left  thigh  e.xplored  through  incision  on  outer 
side  ;  no  bare  bone  felt,  and  posterior  triangular  space  was  healthy,  but  bone  was  enlarged, 
so  a  circular  opening  was  made  with 
a  gouge,  and  deep  in  the  centre  of  the 
bone  was  found  a  cavity  containing 
pus  and  pus-infiltrated  bone ;  on  clear- 
ing out  this  a  cavity  the  size  of  the 
top  of  the  thumb  was  left  with  scle- 
rosed walls.  On  the  right  side  bare 
bone  was  felt  behind  and  above  the 
internal  condyle  ;  a  precisely  similar 
operation  was  done  and  just  the  same 
condition  found,  together  with  several 
small  hard  sequestra.  This  cavity 
communicated  by  a  circuitous  course 
with  the  sinus  on  the  outer  side  ;  this 
was  only  found  out  by  injecting  lotion. 
A  small  sequestrum  was  also  removed 
from  the  humerus.  Wounds  syringed 
out  with  chloride  of  zinc  and  filled 
with  iodoform.  Some  cellulitis,  &c., 
followed,  but  he  did  fairly  well  up  to 
a  certain  point,  and  was  discharged 
July  31.  He  was  subsequently  re- 
admitted with  the  disease  in  the  right 
thigh  extending,  and  was  still  under 
treatment  in  1892.  He  is  now  lost 
sight  of. 

Abscess  in  bone  is  not  limited 
to  childhood,  but  very  frequently 
begins  before  puberty,  though 
many  of  these  patients  do  not 
come  under  treatment  until  the 
disease  is  of  long  standing. 
Though  most  commonly  met 
with  in  the  cancellous  tissue  of 
the  extremities  of  the  long  bones,  abscess  may  also  occur  in  the  shaft,  and 
we  have  more  than  once  had  to  trephine  for  circumscribed  abscess  in  the 
middle  of  the  shaft  (of  the  femur  or  tibia)  occurring  many  years  after  an 
attack  of  acute  periostitis.  Inflammation  of  bone  due  to  typhoid  may 
become  active  after  a  quiescent  period  of  twenty  or  more  years. 

Treatment. — As  in  acute  periostitis,  there  is  but  one  thing  to  be  done  in 
these  cases.  A  free  incision  should  at  once  be  made  down  upon  the  bone, 
and,  either  with  a  gouge  or  trephine,  a  hole  made  into  the  cancellous  tissue 
until  the  abscess  is  reached.  Before  operating  the  exact  spot  of  greatest 
tenderness  should  be  marked,  and  this  is  to  be  the  centre  of  the  incision. 


Fig.  141. ^Epiphysitis  of  the  upper  end  of  the  right  Hu- 
merus, with  softening  and  rela.xation  of  the  ligaments  of 
the  Shoulder  Joint.    The  joint  cavity  was  not  involved. 


654  Diseases  of  the  Bones 

We  have  derived  great  help  from  this  precaution  in  finding  a  small  abscess 
in  bone.  Some  surgeons  prefer  to  do  linear  osteotomy,  i.e.  saw  across  the 
epiphysis  vi'ith  a  fine  saw,  and  thus  open  up  the  abscess  ;  but  this  plan  is  in 
no  way  better  than  the  other.  The  bone  is  usually  found  soft,  red,  and 
rarefied  ;  often  only  a  drop  or  two  of  pus  will  escape,  and  this  may  be 
overlooked.  Even  if  the  abscess  is  not  found,  relief  is  almost  sure  to 
follow,  and  pus  will  be  discharged  in  a  day  or  two  ;  at  the  same  time,  if 
no  abscess  is  found,  careful  exploration  should  be  made  in  every  direction 
for  the  matter,  to  diminish  the  risk  of  its  opening  into  the  joint.  Should  a 
sequestrum  be  found,  it  will  be  of  course  removed,  and  the  cavity  should  be 
well  scraped  out  and  drained  ;  should  the  adjacent  joint  be  involved,  it 
must  be  treated  like  any  other  suppurating  joint. ^ 

Cbronic  Diffuse  Osteomyelitis.- — -This  disease  is  met  with  chiefly  as  a 
tuberculous  or  as  a  pysemic  condition  ;  it  may  result  from  extension  from  a 
primary  periostitis,  or  originate  in  the  medulla,  perhaps  most  often  beginning 
in  the  epiphysial  line.  It  is  a  matter  of  extreme  difficulty,  and  sometimes 
impossilDle,  to  be  sure  whether  a  given  lesion  has  begun  as  a  local  periostitis, 
spreading  afterwards  to  the  epiphysial  line,  or  whether  the  epiphysial  lesion 
is  primary  and  the  periostitis  secondary. 

The  tuberculous  disease  in  a  well-marked  case  is  a  remarkable  lesion  ;  the 
child  has  perhaps  a  history  of  some  long-continued  bone  trouble  coming"  on 
after  measles  or  other  illness,  or  after  an  injury  ;  external  examination  shows 
thickening  of  a  large  part  of  a  long  bone,  with  a  sinus  leading  down  to  a 
cavity  in  the  shaft.  At  first  sight  it  appears  that  the  case  is  one  in  which 
either  the  periostitis  is  the  main  lesion,  or  a  small  localised  central  inflamma- 
tion has  reached  the  surface  and  then  spread  along  the  periosteum  ;  but  on 
cutting  down  upon  the  cavity,  and  clearing  it  out,  a  small  sequestrum, 
infiltrated  with  pus,  and  greenish-yellow  in  colour,  is  removed.  Instead, 
then,  of  finding  the  walls  of  this  cavity  formed  of  healthy  but  sclerosed  bone, 
they  are  soft  and  also  infiltrated  with  pus,  showing  the  same  greenish  colour 
as  the  sequestrum.  There  is  no  sharp  line  of  demarcation  between  this 
green  bone  and  the  surrounding  shaft,  but  patches  of  rarefied  pale  bone  are 
seen  in  parts.  On  attempting  to  gouge  away  the  diseased  tissue  it  will 
often  be  found  to  extend  throughout  a  great  part  of  the  shaft,  and  perhaps 
several  inches  of  cancellous  tissue  are  thus  removed  before  living  bone  is 
reached.  When  all  has  been  removed  the  cavity  slowly  fills  up,  leaving  a 
sinus  or  two.  Some  months  after,  on  exploring  these  sinuses,  a  similar 
condition  is  found  ;  the  purulent  infiltration  has  again  gone  on  spreading, 
and  in  time  it  may  reach  an  adjacent  joint  and  set  up  disease  there.  In  such 
cases  the  compact  tissue  is  usually  healthy  in  appearance,  though  sometimes 
it  is  perforated,  and  there  is  generally  some,  but  not  always  great,  periosteal 
thickening.  In  other  instances  where  the  changes  have  been  rather  more 
active,  the  diseased  part  becomes  isolated  and  sequestra  are  thrown  off 
('chronic  circumscribed  osteomyeHtis,' '  central  necrosis').  Sometimes  the 
compact  tissue  also  dies  ('total  necrosis').  Though  this  disease  mostly 
commonly  affects  the  long  bones,  it  may,  as  already  pointed  out,  attack  the 
jaw  ;  here  even  the  new  bone  may  become  infiltrated,  and  die  as  fast  as  it 
1  The  subject  of  acute  suppurative  arthritis  in  infants  (acute  epiphysitis)  is  treated  more 
specially  under  Diseases  of  the  Joints. 


Chrofiic  Diffuse  Osteomyelitis  655 

is  formed  ;  it  is,  ho\vc\er,  doubtful  whether  this  condition  in  the  case  of  the 
jaw  is  tuberculous  {vide  Diseases  OF  THE  Alimentary  Canal). 

Case. — Alveolar  Abscess,  Necrosis  of  Jaiv. — Joseph  P.,  age6  years  ;  admitted  May  31, 
1884.  Fairly  healthy  till  four  months  ago,  when  he  had  toothache  ;  tooth  extracted,  but 
swelling  did  not  subside.  On  admission,  much  swelling  over  right  side  of  lower  jaw. 
From  socket  of  first  lower  molar,  which  is  gone,  pus  and  granulation  tissue  e.xude. 
June  4,  alveolus  cleared  out ;  some  small  pieces  of  bone  and  a  rudimentary  permanent 
tooth  removed.  Discharged  June  4.  Readmitted  June  23,  with  more  pain,  swelling,  and 
discharge ;  external  incision  made  and  pus  let  out.  June  26,  swelling,  &c.  increased ;  a 
large  sequestrum  removed  from  inside  the  mouth,  and  several  more  through  the  external 
opening;  these  sequestra  were  soft,  foetid,  and  pus-infiltrated,  and  formed  part  of  the 
horizontal  and  ascending  rami  throughout  their  entire  thickness  ;  the  cavity  left  extended 
nearly  up  to  the  joint  ;  some  new  bone  had  been  formed  and  died  subsequently.  July  9, 
discharged  much  relieved. 

The  scapula,  clavicle,  ribs,  pelvis  and  sternum,  and  facial  bones  are  also 
sometimes  attacked,  and  disease  of  adjacent  joints  may  occur  by  extension. 
Though  the  malar  and  upper  ja^\'  bones  are  often  affected,  we  have  seldom 
seen  any  of  the  bones  of  the  vault  of  the  skull  attacked,  except  the  temporal, 
and  this  has  been  a  result  of  disease  of  the  ear.  The  occipital  we  have 
once  seen  perforated  by  tuberculous  disease,  and  in  the  same  child  the 
frontal  bone  was  carious.  The  process  is  essentially  alike  in  all  these  cases. 
The  sequestra  are  generally  soft,  and  in  some  cases  the  pus  decomposes  and 
they  become  foetid,  but  this  is  not  by  any  means  generally  so  in  the  limb 
bones. 

A  similar  condition  is  found  in  the  epiphyses  of  the  long  bones  without 
the  shaft  being  involved  ;  sometimes  a  whole  epiphysial  nucleus  will  die 
and  shell  out  as  a  sequestrum.  We  have  met  with  the  same  condition  in  the 
patella,  leading  to  destruction  of  the  knee  joint.' 

C.\SE. — Necrosis  of  tJie  Patella.  Disease  of  Knee  Joint.-:-] ohn  R. ,  age  7^  years  ;  ad- 
mitted July  7,  1882.  Ten  weeks  ago  had  a  blow  on  the  left  knee,  which  became  painful  a 
week  later.  On  July  2  it  began  to  discharge  ;  his  health  had  been  failing  since  an  attack 
of  whooping  cough  eighteen  months  ago  ;  phthisis  in  family.  On  admission,  a  fluc- 
tuating swelling  mapping  out  the  left  knee  joint,  a  little  redness  and  venous  turgidity  ;  a 
half-closed  sinus  lay  over  the  ligt.  patellae  ;  limb  nearly  straight ;  no  pain.  July  18,  sinus 
explored  ;  it  was  found  to  lead  upwards  into  a  cavity  in  the  patella,  from  which  a  seques- 
trum, the  size  of  a  damson  stone,  was  removed.  The  joint  w^s  incised  on  each  side,  and 
a  free  comnmnication  found  to  exist  between  the  joint  and  the  sinus  through  the  patella ; 
coagulated  lymph  and  serous  fluid  escaped  from  the  joint  ;  operation  antiseptic.  August  17, 
has  done  well,  and  line  of  incision  was  healed  except  at  entry  of  drainage  tube  ;  very 
little  discharge ;  general  condition  good ;  no  fever  since  operation.  August  29,  dis- 
charged in  a  back  splint ;  readmitted  in  October ;  wounds  healed  ;  passive  movement 
attempted,  but  adhesions  found  to  be  strong  and  universal,  not  giving  any  hopes  of 
a  movable  joint,  so  he  was  fixed  in  a  back  splint  with  plaster  of  Paris,  and  sent  out 
November  15. 

In  this  chronic  osteomyelitis,  an  epiphysial  line  acts  only  as  an  imperfect 
barrier,  and,  where  the  disease  begins  in  it,  it  usually  spreads  both  upwards 
towards  the  joint  and  downwards  into  the  shaft.  When  the  whole  epiphysis 
is  involved,  the  articular  cartilage  may  be  exposed  on  the  removal  of  the 
infiltrated  bone,  and,  as  its  nutrition  is  cut  off  from  the  side  of  the  bone,  it 

1  \'ide  Lancet,  March  1883  ;  also  Children  s  Hospital  Abstracts,  1882.  Since  then  we 
have  seen  two  or  three  similar  cases. 


656  Diseases  of  the  Bones 

usually  gives  way,  and  in  such  cases  the  joint  becomes  involved.  We  have, 
however,  seen  a  case  where  complete  recovery  with  a  movable  joint  occurred 
although  the  articular  cartilage  was  thus  exposed. 

Case. — Osteomyelitis  of  Tibia. — Annie  L. ,  age  3  years  ;  admitted  November  4,  1884. 
History  good.  In  June  1884  fell  downstairs  ;  in  August  first  complained  of  pain  in 
left  leg  ;  it  then  began  to  swell,  and  has  been  slowly  increasing  ever  since — rapidly  during 
the  last  fortnight ;  health  failing  ;  has  pain  at  night,  &c.  On  admission,  tense  swelling  of 
nearly  the  whole  tibia  and  the  soft  parts  over  it  ;  skin  shining,  but  not  red  ;  temperature 
98  "6°.  Three  incisions  were  made  over  the  front  and  outer  side  down  to  the  bone,  but  no 
pus  escaped.  She  was  relieved,  pain  disappeared,  and  swelling  subsided.  She  was  dis- 
charged on  November  18.  Readmitted  December  16,  1884.  The  left  tibia  is  enlarged  in 
nearly  its  whole  length,  and  is  very  tender  on  palpation  over  its  lower  third.  Some  pro- 
minence of  superficial  veins  just  above  the  ankle,  but  no  discoloration  of  skin  and  no 
fluctuation  ;  temperature  normal.  January  8,  under  spray,  incision  made  over  tibia  just 
above  the  ankle  ;  periosteum  found  much  thickened  ;  a  small  gouge  was  easily  pushed  into 
the  centre  of  the  bone,  and  some  pus  welled  up  ;  a  quantity  of  soft  disintegrating  bone, 
infiltrated  with  pus,  was  gouged  away  until  a  faii'ly  healthy  sm'face  was  reached  ;  drainage 
tube  inserted  ;  iodoform  and  wood-wool  dressing.  On  January  19  tube  removed  ;  and  on 
February  2  wound  almost  healed,  but  leg  not  diminished  in  size,  and  presents  same 
general  characters  as  on  admission.  Readmitted  March  30,  1885.  The  wound  from  last 
operation  has  not  healed,  and  is  still  discharging  ;  swelling  has  spread  up  the  tibia  as  far 
as  knee-joint ;  considerable  thickening.  April  30,  no  change  in  condition  ;  temperature 
occasionally  100°  at  night.  Esmarch's  bandage  applied,  and  incision  afterwards  made, 
about  2b  inches  long,  over  lower  third  of  tibia  ;  periosteum  detached  and  a  new  casing  of 
bone,  about  \  inch  thick,  exposed  ;  on  cutting  through  this  with  a  chisel,  softened  bone 
infiltrated  with  pus  was  removed,  and  at  lower  end  a  sequestrum  about  2  inches  long  was 
extracted.  A  second  incision  was  afterwards  made  over  upper  third  of  tibia,  and  the  bone 
found  in  similar  diseased  condition  ;  the  whole  of  the  interior  of  the  tibia  was  gouged  and 
scraped  out,  so  that  a  probe  could  be  passed  from  the  upper  to  the  lower  opening ;  iodo- 
form and  wood-wool  dressings  and  back  splint  applied.  May  26,  lower  wound  healing  ; 
still  large  cavity  at  upper;  much  discharge  ;  temperature  hectic,  96"4"-ioo"4°  ;  takes  food 
well.  June  9,  wounds  slowly  filling  up  ;  suppurating  glands  at  angle  of  jaw  opened  ; 
temperature  98°-i02°.  June  29,  wounds  superficial,  but  still  much  discharge.  July  20, 
lower  wound  almost  healed  ;  upper  filling  up  and  contracting  ;  less  discharge  ;  tempera- 
ture normal.  August  11,  still  slight  discharge  from  both  wounds  ;  sent  home  on  back 
splint.  Readmitted  October  24.  Leg  more  swollen  than  when  last  in  hospital ;  still  two 
sinuses  over  left  tibia.     The  limb  was  finally  amputated,  as  the  joint  became  involved. 

The  other  forms  of  diffuse  inflammation  which  may  attack  the  marrow 
of  bones  have  been  already  mentioned  :  in  the  rarefying  form  the  medulla  may 
be  replaced  by  deep  red  or  maroon-coloured  granulation  tissue,  and  the 
bone  may  become  so  soft  as  to  readily  break  down  under  the  finger  ;  such 
condition  may,  however,  be  recovered  from.  We  have  known  a  case  where 
the  femur  was  so  affected,  and  recovery  took  place  without  any  unusual 
difficulty. 

In  sclerosing  or  condensing  osteomyelitis  the  medullary  cavity  may  be 
almost  entirely  filled  up  with  irregular  dense  masses  of  bone,  and  sometimes 
isolated  central  sequestra  exist  under  such  circumstances.' 

Scattered  miliary  tubercles  may  sometimes  be  found  in  the  medulla  of 
bone  as  a  part  of  a  general  tuberculosis  ;  they  are,  however,  only  found  post 
mortem^  as  they  give  rise  to  no  symptoms  during  life. 

1  A  combination  of  these  two  conditions  appears  to  ha\e  existed  in  a  case  recorded  by 
Mr.  Paul  in  the  Med.  Press  and  Circ.  1884. 


Stj'uvious  Dactylitis  6$y 

The  pya^mic  variety  of  osteomyelitis  is  occasional!}'  met  with.  In  one  of  the  most 
characteristic  cases  that  we  have  seen,  a  boy  eleven  years  old,  who  was  in  the  habit  of 
getting  wet  and  drying  his  clothes  on  him,  complained  of  pain  in  the  feet ;  the  right  foot 
and  subsequent!}'  the  knee  swelled,  the  latter  suppurated  and  discharged  profusely  a  fort- 
night later  ;  the  left  elbow,  the  right  hip,  and  the  left  knee  then  were  attacked.  On 
admission,  ten  weeks  after  the  onset  of  the  illness,  both  hips,  both  knees,  and  the  right 
ankle,  the  left  elbow,  and  the  left  shoulder,  were  swollen  ;  there  were  bedsores,  and  he 
had  a  systolic  murmur  and  some  evidence  of  pneumonia  ;  the  urine  was  albuminous  ;  he 
was  much  wasted,  and  his  skin  was  dry  and  harsh.  A  month  after  admission  the  left 
elbow  was  incised  ;  at  that  time  there  was  brawny  thickening  over  the  upper  part  of  the 
same  arm  ;  ten  days  later,  on  e.xploring  the  liumerus,  there  was  found  to  be  extensive  but 
ill-defined  mischief  in  it ;  a  fortnight  after,  the  disease  had  e.xtended  so  that  the  whole 
humerus  was  the  seat  of  osteomyelitis  ;  pus  discharged  freely  from  the  medulla  at  the 
upper  part  of  the  bone.  The  limb  was  amputated  at  the  shoulder  joint ;  in  doing  so  a 
large  axillary  abscess  was  opened.  The  shoulder  joint  was  healthy,  the  elbow  disorganised  ; 
there  was  a  sequestrum  at  the  surgical  neck  of  the  humerus.  He  recovered  fairly  well 
from  the  operation,  but  subsequently  fresh  mischief  occurred  in  the  thigli,  and  he  was 
removed  by  his  friends,  probably  to  die. 

Treatment  of  Chronic  Osteomyelitis. — The  treatment  of  the  different 
forms  of  chronic  osteomyelitis  has  been  almost  sufficiently  indicated  in  the 
description  of  the  disease.  The  general  management  will  be  that  of 
tuberculous  children  :  locallj^,  in  the  early  stages,  rest  to  the  part  by  means 
of  splints,  and  in  some  cases  confinement  to  bed,  is  all  that  can  be  done.  If 
the  disease  does  not  subside,  the  bone  must  be  freely  exposed — the  limb 
having  been  made  bloodless  by  the  elastic  bandage,  and  the  bone  gouged 
away,  all  tissue  that  is  dead  or  infiltrated  with  pus  being  removed  ;  if  the 
mischief  spreads  far  along  the  medulla,  a  groove  must  be  cut  in  the  bone, 
and  all  affected  cancellous  tissue  scraped  away.  Should  no  repair  take  place 
and  the  disease  spread  to  an  adjacent  joint,  if  the  child's  health  is  good,  an 
attempt  may  yet  be  made  to  save  the  limb  by  incising  the  joint  and  draining 
it  ;  in  some  cases,  however,  nothing  seems  to  arrest  the  disease,  and  ampu- 
tation is  required. 

Washing  out  cavities  with  carbolic  or  mercurial  lotion  ( [  in  4,000),  and 
free  dusting  with  iodoform,  is  perhaps  the  best  wound  treatment.  In  some 
cases  it  is  a  good  plan  to  try  the  application  of  the  actual  cautery  to  the 
interior  of  the  bone,  in  the  hope  of  arresting  the  tuberculous  process.  In 
pyfemic  cases  incision  of  abscesses,  removal  of  sequestra,  and  amputation 
are  the  only  local  resources,  and  each  case  has  to  be  judged  on  its  own 
rec|uirements. 

'  Strumous  Dactylitis.' — The  condition  sometimes  called  '  strumous 
dactylitis  '  requires  brief  mention  here.  The  disease  is  simply  chronic  tuber- 
culous osteomyelitis,  or  more  rarely  periostitis,  attacking  usually  the  first 
phalanx  of  one  or  more  fingers  ;  sometimes  the  metacai'pal  or  metatarsal 
bones  are  affected.  The  disease  usually  begins  as  a' hard,  painless  swelling 
of  that  segment  of  the  finger,  though  occasionally  there  is  a  good  deal  of  pain, 
and  always  some  tenderness.  If  no  treatment  is  employed,  the  swelling 
increases,  the  soft  parts  become  involved,  abscesses  ^  appear  usually  at  the 

1  It  must  be  understood  that  here  as  elsewhere  the  words  '  abscess  '  and  '  pus  '  are,  in 
relation  to  tuberculous  lesions,  used  in  a  sense  implying  the  naked-eye  appearance  rather 
than  the  actual  pathological  condition.     The  '  pus '  is  broken-down  caseous  tuberculous 

U  U 


658 


Diseases  of  t/ie  Bones 


sides  of  the  finger,  and  on  their  bursting  or  being  opened  thick  curdy  pus, 
with,  perhaps,  some  bony  detritus,  escapes.  On  further  examination,  a  large 
cavity  is  found  occupying  the  site  of  the  old  shaft,  which  is  either  entirely 
gone  or  remains  in  part  as  a  cheesy  sequestrum,  or  in  some  cases,  if  the 
abscess  is  opened  early,  appears  to  be  simply  bare.     Around   the  cavity, 


\ji  <ji 


Ot^, 


Fig.  142. — Multiple  '  Tuberculous 
Dactylitis.' 


Fig.  143. — Shows  overgrowth  of  one  Thumb, 
which  had  been  long'the  seat  of  Tuberculous 
disease.  This  is  a  rare  condition,  and  should 
be  compared  with  fig.  139  of  overgrowth  of 
the  tibia. 


which  is  filled  with  pus  and  caseous  matter,  is  a  thin  layer  of  new  bone 
formed  by  the  periosteum.  As  successive  layers  of  new  bone  have  been 
laid  down  and  absorbed,  so-called  '  expansion '  of  the  bone  has  occurred. 
After  removal  of  all  the  cheesy  matter  and  sequestra  the  finger  may 
gradually  shrink  and  get  well,  but  is  shortened,  distorted,  and  usually  weak 


ii/j  iiiiy 


Fig.  144. — The  hands  of  an  adult  showing  the  efi'ects  of  Tuberculous  Dactjditis  in  childhood. 

and  useless.  Sometimes  the  destruction  is  so  great  that  amputation  is 
required.  When  seen  in  the  earlier  stages,  constitutional  treatment,  with 
fixation  of  the  finger  on  a  splint  and  gentle  pressure,  will  sometimes  succeed 

material  diluted  with  serum,  and  mi.xed  with  simple  inflammatory  products,  and  not  the 
true  pus  of  an  acute  abscess. —  Vide  Watson  Cheyne's  Lectures,  Brit.  Med.  Jour.  1890, 
for  a  good  description  of  the  process. 


SypJiilitic  Dactylitis — Leontiasis  Ossea  659 

in  arresting  the  disease.  It  has  been  recommended  to  excise  the  bone  sub- 
pcriosteally  in  the  early  stage,  and  this  would  no  doubt  cut  short  the  disease, 
l)ut  the  finger  is  not  likely  to  be  of  much  use.  It  is  better  treatment  to  wait 
patiently,  and  keeping  the  finger  quietly  fixed  on  a  splint  to  try  the  effects 
of  pressure  and  general  hygiene  ;  when  sequestra  are  pi'esent  they  must, 
of  course,  be  removed,  and  should  no  progress  be  made  the  cavity  must  be 
cleared  out — but,  as  a  rule,  a  more  useful  finger  is  obtained  by  expectant 
than  by  active  treatment. 

Should,  however,  abscess  form,  the  best  plan  is  to  freely  open  and 
carefully  scrape  out  the  abscess  cavity,  removing  all  caseous  material.  The 
cavity  should  then  be  well  dusted  with  iodoform  and  boric  acid  or  some 
iodoform  emulsion  injected,  and  the  wound  should  be  closed  by  sutures 
without  drainage.  Primary  union  will  usually  be  obtained  if  the  wound  is 
kept  aseptic. 

Often  many  fingers  are  affected,  and  the  disease  is  most  commonly  a 
part  of  '  General  Surgical  Tuberculosis  ; '  it  is  most  frequently  met  with  in 
the  first  few  years  of  life.  The  disease  is  probably  sometimes  periosteal 
rather  than  endosteal. 

'  Syphilitic  Dactylitis,'  so  called,  is  more  often  described  than  met  with. 
The  general  appearance  closely  resembles  that  of  '  strumous  dactylitis,'  and 
it  is  said  that  in  children  the  disease  is  usually  primarily  an  osteomyelitis, 
though  the  gummatous  material  may  be  deposited  first  either  in  the  peri- 
osteum or  soft  tissues  overlying  it.  The  occurrence  of  '  dactyfitis  '  in  a  child 
showing  other  signs  of  congenital  syphilis  would  lead  to  a  suspicion  that  the 
affection  of  the  fingers  was  also  specific.  The  results  are  usually  very  much 
the  same  as  those  of  the  tuberculous  lesion,  and  the  treatment  is  simply  that 
of  syphilis.^ 

'  Iicontiasis  Ossea  '  is  a  disease  in  which  the  bones  of  the  face,  especially 
the  upper  and  lower  jaws  and  the  malar  bones,  undergo  hypertrophy.  The 
disease  begins  in  early  hfe  and  may  go  on  indefinitely.  In  a  case  we  saw 
which  had  been  under  the  care  of  Dr.  Brown,  of  Bacup,  and  Mr.  T.  Jones, 
the  disease  began  at  9  years  old,  and  the  patient  when  we  saw  him  was  28. 

We  have  under  our  care  now,  1899,  a  boy  in  whom  the  disease  began  as 
a  slowly  increasing  thickening  of  the  ascending  ramus  of  the  lower  jaw  ;  the 
temporal  bone,  maxilla,  and  malar  are  now  affected,  and  the  nasal  process 
of  the  opposite  maxilla  is  beginning  to  enlarge.  No  medicinal  treatment 
has  had  any  effect. 

1  Vide  Eschle  in  Langenbeck' s  A)-chiv,  xxxvi.  1887  ;  or  an  abstract  in  Aled.  Chron. 
February  1888. 


66o  Diseases  of  the  Joints 


CHAPTER    XXX 

DISEASES    OF   THE   JOINTS 

Diseases  of  the  Joints.— There  is  no  essential  difference  between  the 
joint  diseases  of  children  and  those  of  adults,  but  certain  forms  of  disease 
are  found  most  typically,  or  even  almost  entirely,  in  childhood.  The  con- 
ditions of  growth  as  regards  the  relations  of  epiphyses  to  the  adjacent  joints 
and  to  the  shaft  of  the  bone  are,  however,  most  important  factors  in  deter- 
mining the  occurrence  of  disease  and  the  kind  of  lesion  met  with,  and, 
further,  the  liability  of  children  to  the  various  exanthemata  is  of  much 
importance  in  regard  to  joint  affections.  Ordinary  acute  synovitis  from 
injury  or  cold  is  in  no  way  peculiar  to,  nor  even  specially  common  in, 
children,  and  need  not  be  discussed  here  ;  while  hip  disease,  acute  sup- 
purative arthritis  of  infants,  scarlatinal  synovitis,  and  even  the  common 
tuberculous  pulpy  disease,  are  instances  of  the  modifying  effects  of  the  condi- 
tions of  childhood  upon  forms  of  lesion  which  are  also  to  be  met  with  in  adults. 

In  early  life  the  lesions  of  joints  are  more  complex  than  in  adults,  for 
the  reason  already  alluded  to,  that  not  only  may  disease  begin  in  the  joint 
structures  proper,  but  it  may  often  reach  the  articulation  by  extension  from 
the  neighbouring  epiphysis  or  epiphysial  line.  It  is  generally  said  that  bone 
lesions  are  limited  by  the  epiphysial  zone  and  do  not  extend  to  the  bone 
below  ;  this,  as  already  shov>'n,  is  only  partially  true,  and,  besides  this,  disease 
spreads  frequently  from  a  starting  point  in  the  epiphysial  line,  or  from  the 
periosteum  of  the  diaphysis,  and  extends  to  the  capsule,  and  so  to  the  synovial 
membrane.  There  is,  however,  often  effusion  into  a  joint  adjacent  to  bone 
disease  without  actual  continuity  of  disease.  (For  furthur  details  see  chapter 
on  Bone  Diseases.) 

Joint  disease,  then,  in  children  may  arise  as  a  simple  acute  serous 
synovitis,  which  may  subside,  suppurate,  or  become  chronic.  Chronic 
simple  serous  synovitis  is,  however,  rare  in  children.  There  may  be 
a  primary  acute  or  chronic  tuberculous  synovitis.  Pyaemia  or  certain  of  the 
exanthems,  notably  scarlatina  and  typhoid,  may  give  rise  to  an  acute,  some- 
times suppurative,  synovitis,  while  measles  and  whooping  cough,  as  well  as 
scarlet  fever  and  typhoid,  may  result  in  a  development  of  tuberculous  lesions. 
Finally,  the  joint  disease  may  arise  by  extension  from  the  shaft,  epiphysial 
line,  or  from  the  epiphysis  itself,  and  possibly  from  the  ligaments  and 
tendon  sheaths  in  exceptional  cases.  The  specific  fevers  are  not  so  often, 
as  is  sometimes  stated,  the  direct  cause  of  joint  disease  :  it  is  in  most  cases 


Pathology  of  Jomt  Diseases  66 1 

rather  that  the  depressing  efifect  of  the  fevers  makes  the  child  more  hable  to 
the  onset  of  disease — thus  of  125  cases  of  joint  disease,  taken  consecutively 
from  our  records,  including  cases  of  disease  of  the  hip,  knee,  shoulder, 
elbow,  ankle  and  tarsus,  and  wrist  joints,  in  only  six  cases  was  the  joint 
affection  a  sequela  of  measles,  in  four  of  scarlet  fever,  in  two  of  typhoid,  and 
in  three  of  whooping  cough.  Only  those  cases  were  reckoned  in  which  there 
was  no  interval  of  health  between  the  exanthem  and  the  joint  trouble. 

In  certain  joints  bone  lesions  are  far  most  commonly  prinjary,  as  in  the 
hip,  and  perhaps  the  shoulder ;  in  other  joints,  as  in  the  knee,  ankle,  and 
wrist,  bone  disease  when  present  is  much  more  often  secondary  to  a  primary 
synovial  inflammation,  while  in  other  joints  again,  as  in  the  elbow,  either 
starting  point  is  common. 

The  hip  is  by  far  the  most  frequently  diseased  joint  in  children,  and  the 
knee  comes  next.  Of  698  cases  of  joint  disease  under  our  care  in  the  out- 
patient department  of  the  Children's  Hospital  in  three  years,  369  were  cases 
of  hip  disease,  160  of  knee  disease,  and  all  the  other  joints  together  amounted 
to  169.     Disease  of  the  spine  is  excluded  from  this  calculation. 

For  any  detailed  account  of  the  pathology  and  symptoms  of  each  diseased 
joint  we  must  refer  to  the  special  works  of  Barwell,  Macnamara,  Howard 
Marsh,  Hueter,  and  others  ;  space  will  only  allow  of  selection  of  the  hip  and 
knee  as  types  of  the  two  forms  of  joint  disease  found  in  childhood,  with  a 
brief  reference  to  the  other  most  commonly  affected  articulations.  Hip 
disease  stands  so  much  by  itself  that  its  consideration  will  be  most  con- 
veniently postponed  till  after  that  of  the  other  joints. 

Chronic  disease  of  the  knee  joint  may  be  taken  as  the  type  of  joint 
disease  beginning  in  synovial  membrane — pulpy  disease,  chronic  synovitis, 
tuberculous  synovitis,  white  swelling,  and  various  other  titles,  all  implying  the 
same  condition. 

Here  we  may  say  at  once  that  we  believe  all  the  cases  of  chronic  dis- 
ease of  joirjts  marked  by  great  thickening  of  synovial  membrane,  with  little 
or  no  tendency  to  accumulation  of  fluid,  but  with  great  tendency  to  the 
formation  of  small  multiple  'abscesses'  in  the  thickness  of  the  gelatinous 
tissue,  are  truly  tuberculous  in  the  most  strict  sense.  In  some  cases  a  consider- 
able amount  of  fluid,  either  serous  with  caseous  material  and  flakes  of  lymph, 
or  more  puriform,  is  found  in  the  joint  ;  this  is,  however,  not  a  common  con- 
dition in  children.  In  many  instances  evidence  of  tubercle  elsewhere  and  a 
tuberculous  family  history  will^be  found  ;  ^  in  many,  death  ultimately  results 
from  tuberculosis  of  other  organs.  The  anatomical  characters  of  tubercle 
are  constantly  to  be  found  in  the  pulpy  tissue,  and,  though  not  so  constantly 
or  readily,  yet  in  a  large  number  of  instances  tubercle  bacilli  have  been 
detected. 

The  usual  history  of  a  case  of  chronic  tuberculous  synovitis  of  the  knee 
joint  in  a  child  is  as  follows.  There  is  perhaps  a  history  of  phthisis  or  joint 
disease  in  the  family  ;  the  child  has  been  healthy,  till  at  the  age  of,  say,  four 
years  it  was  attacked  by  measles  or  some  other  exanthem.     It  was  slow  in 

^  In  192.  histories  of  chronic  joint  disease  under  our  care  (the  spine  being  included),  in 
43  ( -1-  6  doubtful  cases)  there  was  a  tuberculous  family  history  ;  in  6i  (  +  i  doubtful  case)  the 
disease  had  followed  an  injury.  In  19  cases  out  of  11 1  patients  there  was  more  than  one 
lesion,  i.e.  there  was  evidence  of  tubercle  elsewhere. 


662  Diseases  of  the  Joints 

recovery,  and  was  never  quite  strong  afterwards ;  a  year  later,  perhaps,  it 
received  some  injury  to  the  knee.  Shortly  after  the  knee  swelled,  but  gave 
rise  to  no  great  pain  or  inconvenience,  except  a  slight  limping  and  feehng 
of  tiredness  ;  the  swelling  slowly  increased  and  became  somewhat  more  pain- 
ful, especially  at  night,  with  night  startings.  We  cannot  too  strongly  insist 
upon  the  fact  that  tuberculous  disease  of  joints  may  go  on  for  months,  steadily 
getting  worse,  without  any  pain  at  all,  and  with  but  little  impairment  of 
mobility  ;  this  so  frequently  occurs,  and  yet  is  so  frequently  a  cause  of  mis- 
takes, that  we  desire  to  emphasize  the  statement  here.  At  this  time  the  child 
we  will  suppose  comes  under  observation.  The  knee  is  found  markedly 
larger  in  circumference  than  its  fellow,  its  natural  hollows  are  obliterated,  it 
may  or  may  not  be  slightly  hotter  than  the  other,  there  is  slight  flexion,  and 
usually  it  cannot  be  fully  extended,  any  attempt  to  do  so  causing  pain. 
There  is  considerable  pain  on  pressure  over  the  inner  tuberosity  of  the  tibia, 
and  to  a  less  degree  over  the  outer  side.  The  swelling  is  soft,  elastic,  and 
pseudo-fluctuating  :  it  may  exactly  follow  the  normal  outlines  of  the  joint,  or 
be  more  globular,  the  upper  synovial  pouch  not  being  thickened  ;  occasion- 
ally the  swelling  is  almost  limited  to  the  upper  sac.  There  is  pretty  free 
mobility  of  the  joint  at  this  stage,  unless  an  attack  of  acute  inflammation  has 
supervened  upon  the  chronic  mischief.  Such  a  case  left  to  itself  will  later  on 
become  more  flexed  and  less  mobile,  abscesses  will  form  and  burst  at  the 
sides  or  front  of  the  joint,  the  swelling  will  increase,  and  the  veins  over  the 
surface  may  become  dilated  and  full  ;  the  tibia  will  become  subluxated  back- 
wards and  outwards,  and  at  the  same  time  rotated  outwards  upon  the  femur  ; 
the  limb  will  become  wasted  and  powerless.  In  many  cases  pain  increases 
and  the  child's  health  suffers,  until  at  last  the  pain  and  discharge,  or  the 
invasion  of  other  organs  by  tubercle,  wears  him  out. 

The  severity  of  the  symptoms  varies  greatly  :  in  some  instances  pain  and 
stiffness  exist  throughout  ;  in  others  free,  though  not  usually  full,  mobility 
and  absence  of  pain  may  be  found  during  nearly  the  whole  course  of  the 
disease. 

If  a  knee  joint,  such  as  the  one  described,  is  laid  open,  the  synovial 
membrane  is  found  everywhere  converted  into  a  thick,  pinkish-grey  or 
yellowish,  semi-transparent  material,  soft  and  gelatinous  to  the  touch,  but  in 
parts  tough  and  elastic  ;  in  parts  the  grey  tissue  is  streaked  with  opaque 
fibrous  bands,  and  here  and  there  caseous  foci  will  be  found  softening  and 
breaking"  down — these  are  especially  common  towards  the  posterior  part  of 
each  femoral  condyle.  These  breaking-down  foci  do  not  usually  commu- 
nunicate  with  the  cavity  of  the  joint  itself,  which  is  largely  filled  up  by  the 
thick  granulation  masses,  and  contains  little  or  no  fluid. 

The  pulpy  tissue  grows  over  the  cartilages  at  first  in  delicate  vascular 
tendrils  or  films,  but  afterwards  these  become  thicker  and  form  fleshy  pads 
replacing  the  cartilage  at  the  edge  and  lying  in  pits  dug  out  of  its  surface, 
so  that  finally  only  a  small  central  island  of  healthy  cartilage  remains  in  the 
middle  of  each  condyle  and  each  articular  surface  of  the  tibia. 

Often  granulation  sprouts  spread  beneath  the  cartilage  and,  detaching" 
it  from  the  bone,  give  rise  to  superficial  rarefying  ostitis, '  subchondral  caries,' 
which  causes  necrosis  and  separation  of  the  articular  cartilages. 

The  semilunar  cartilages  are  as  it  were  embedded  in  the  gelatinous  tissue, 


Disease  of  the  Knee  66}^ 

and  in  some  far  advanced  cases  can  hardly  be  distinguished  ;  usually, 
however,  they  are  readily  made  out.  The  crucial  ligaments  are  coated  over 
with  the  pulpy  tissue,  and  are  often  very  vascular,  with  bright  streaks  of  vessels 
running  along  them  ;  on  scraping  away  this  tissue  the  ligaments  are  found  to 
have  nearly  their  natural  appearance,  except  that  here  and  there  a  little 
sprout  has  forced  its  way  between  their  fasciculi.  The  degree  of  destruction, 
however,  of  course  varies  in  different  cases,  and  in  some  the  tuberculous  focus 
is,  at  first,  strictly  limited  to  one  patch  of  synovial  membrane. 

The  cavity  of  the  joint  is  often  subdivided  into  loculi  by  adhesions  be- 
tween masses  of  the  granulation  tissue.  On  gouging  out  one  of  the  granula- 
tion pits  in  the  cartilage,  it  will  be  found  in  some  cases  not  to  extend  through, 
in  others  the  bone  beneath  is  reached  and  locally  eroded. 

The  capsule  and  lateral  ligaments,  &c.  are  much  thickened,  and  this 
gives  rise  to  the  deceptive  sensation  of  bony  thickening  so  often  met  with  in 
the  knee.  However  much  it  may  appear  that  there  is  enlargement  of  the 
bones  in  a  case  of  chronic  disease  of  the  knee,  it  is  almost  perfectly  safe  to 
say  that  the  thickening  is  in  the  soft  parts  alone,  and  that  there  is  no  new 
bone  formation.  It  is  only  very  rarely  that  a  layer  of  periosteal  new  bone  is 
found  beyond  the  limits  of  the  capsule.  The  presence  of  new  bone  about  a 
chronic  tuberculous  joint  is  usually  a  sign  of  repair  and  of  subsidence  of 
the  disease  ;  sometimes,  however,  it  is  associated  with  central  bone  disease 
(chronic  osteomyelitis),  never,  we  think,  with  progressive  synovial  diseas'" 
alone.  Mr.  Watson  Cheyne,  however,  states  that  microscopically  thickening 
of  bone  trabecular  precedes  tuberculous  infiltration  in  caries  of  the  articular 
ends  of  bones. 

There  is  usually  more  or  less  atrophy  of  the  bone  adjacent  to  a  chronically 
diseased  joint.  The  cancellous  tissue  is  more  open  in  texture,  and  the  com- 
pact tissue  thinner  than  in  health.  Wasting  of  the  bones,  in  fact,  takes  place, 
just  as  of  the  muscles  and  other  tissues  around  the  joint.  These  changes  are 
general.  When  local  patches  of  marked  rarefaction  are  present,  that  part 
must  be  considered  the  seat  of  actual  disease. 

In  the  great  majority,  however,  of  cases  of  disease  of  the  knee  the  bone 
is  healthy,  unless  the  disease  is  far  advanced  ;  when  this  is  so,  islets  of  soft 
rarefying  bone  and  carious  patches  will  be  found,  the  latter  in  their  early 
stages  being  recognised  by  the  yellow  and  red  mottling  in  the  neighbourhood 
of  the  articular  cartilage,  with  some  rarefaction.  It  is  often  very  difficult  to 
be  certain  of  the  condition  of  bone  in  very  early  stages  of  disease  :  patches 
of  various  shades  of  yellow  and  red  are  met  with  in  perfectly  healthy  bone ; 
where  there  is  any  local  rarefaction  or  opaque  yellow  deposit  disease  is 
present.  In  some  instances,  however,  sequestra  of  varying  size  are  found — 
most  commonly  in  the  femur,  less  often  in  the  tibia  ;  usually  the  necrosis  is 
at  the  back  of  one  or  other  condyle  ;  we  have,  however,  found  it  in  the 
middle  of  the  intercondyloid  notch.  When  necrosis  does  occur  the  disease 
often  tunnels  a  considerable  way  through  the  bone,  or  rather  the  disease  has 
probably  begun  in  the  epiphysial  line  or  epiphysis  itself,  and  extended  towards 
the  joint. 

As  Mr.  Howard  Marsh  has  pointed  out,  a  condition  of  '  quiet  strumous 
disease  '  may  exist,  leading  to  a  stiff  joint  without  any  active  stage  or  suppu- 
ration ;  we  have  seen  such  joints  occasionally,  and  they  are  to  be  distinguished 


664  Diseases  of  the  Joints 

by  having  a  greater  amount  of  solid  thickening  than  occurs  in  serous  syno- 
vitis, but  less  than  in  the  ordinary  tuberculous  joint. 

Tuberculous  Disease  of  the  Shoulder  is  rare  in  children  ;  there  is  hardly 
sufificient  evidence  to  show  how  often  the  disease  begins  in  the  synovial 
membrane  and  how  often  in  bone.  The  swelling  forms  a  globular  mass, 
most  prominent  in  front,  and  stiffness  of  the  joint  is  usually  marked.  When 
suppuration  occurs  the  abscesses  usually  point  behind  or  in  front  of  the  del- 
toid, occasionally  in  the  posterior  triangle  ;  no  information  as  to  the  primary 
lesion  can  be  obtained  from  the  position  of  the  sinuses,  since  extra-articular 
abscesses  due  to  epiphysitis  discharge  in  the  same  spots.  Disease  in  the 
epiphysial  line  may  or  may  not  lead  to  destruction  of  the  joint.  In  one 
interesting  case  we  removed,  as  a  sequestrum,  part  of  the  upper  end  of  the 
diaphysis,  including  the  epiphysial  line,  and  subsequently  nearly  the  whole 
shaft  of  the  humerus  ;  the  inflammation  had  spread  from  the  periosteum 
to  the  capsule,  and  the  ligaments  became  so  relaxed  that  there  was  a  deep 
groove  below  the  acromion,  the  humerus  having  dropped  away  from  the 
scapula;  the  joint  did  not  suppurate,  and  all  went  on  well  (fig.  141). 

We  have  only  two  or  three  times  found  it  necessary  to  excise  the  shoulder 
joint  in  children  ;  in  all  the  other  cases  the  disease  has  subsided,  or  the  case 
has  been  lost  sight  of.  In  one  instance,  where  there  was  much  necrosis,  a 
very  useful  limb  resulted  with  |-inch  shortening,  and  but  little  wasting,  but 
the  joint  was  hardly  at  all  mobile. 

Case. — Disease  of  Shoulder  Joint.  Excision. — Lewis  H.,  age  4  years;  admitted 
July  19,  1882.  Three  years  ago  tlie  left  arm  was  seen  to  be  stiff  and  painful  ;  abscesses 
formed  about  the  shoulder  and  were  opened  ;  no  bone  removed  ;  for  last  eighteen  months 
had  been  discharging  a  little  constantly,  and  lately  the  child  had  lost  flesh  ;  no  phthisis  in 
family  ;  other  children  healthy.  On  admission,  rather  pale,  but  fairly  nourished  boy  ; 
general  thickening  all  round  the  left  shoulder ;  a  patch  of  red  thinned  integument,  with 
pus  beneath,  in  front  of  the  insertion  of  the  deltoid,  and  a  sinus  at  the  posterior  border 
of  the  muscle  :  the  pectoral  fold  bulged  downwards  and  forwards  ;  there  was  pain  in 
movement.  July  26,  much  discharge,  especially  on  pressure  about  the  axilla  ;  very  little 
mobilit}',  even  under  chloroform,  slight  power  of  rotation  alone  remaining.  August  2, 
the  upper  end  of  the  humerus  was  excised,  together  with  about  an  inch  of  the  shaft,  by  a 
single  straight  incision  at  the  anterior  border  of  the  deltoid  ;  two  loose  sequestra  were 
found  in  an  abscess  cavity  surrounding  the  head  of  the  humerus  ;  the  joint  was  entirely 
destroyed ;  the  glenoid  cavity  and  acromion  were  roughened  ;  there  was  some  deposit  of 
new  bone  around  the  upper  part  of  the  shaft  of  the  humerus  ;  the  part  removed  was  not 
entirely  necrosed,  but  there  was  a  large  cavity  in  it ;  terebene  dressings,  hand  slung  up 
to  chest ;  some  rise  of  temperature  followed.  He  went  on  well,  but  slowly  ;  at  one  time 
;^ome  bare  white  bone  was  seen,  but  this  vascularised  subsequently,  except  a  small  part 
removed  on  August  26,  and  two  more  small  pieces  which  came  away  in  September. 
Passive  movement  was  begun  on  September  23,  and  on  the  28th  more  free  movement  was 
made  under  chloroform.  He  had  chicken-pox  in  October,  and  was  discharged  with  sinuses 
still  open  on  November  8.  Passive  movement  failed  subsequently  to  give  him  any  great 
amount  of  mobility.  February  1883,  he  is  well  and  strong,  and  has  good  use  of  the  arm, 
but  the  movement  is  almost  entirely  of  the  scapula  ;  the  limb  is  not  much  wasted,  and 
there  is  |-inch  shortening. 

Disease  of  the  Elbow  Joint  arises  either  as  a  primary  synovitis  or  about 
equally  often  as  disease  of  bone  ;  in  the  latter  case  the  olecranon  or  one 
of  the  condyles,  most  often  the  outer,  is  first  attacked.  Well-marked  cheesy 
masses  are  often  found  in  one  or  other  condyle,  but  any  extensive  disease  of 


Disease  of  the  Elbow  Joint  66  S 

the  radius  is  very  I'are.  Swelling  extends  all  round  the  joint,  but  usually 
appears  first  over  the  radio-humeral  line  at  the  back  of  the  joint.  Later  the 
front  of  the  joint  becomes  swollen  ;  this  is  sometimes  due  to  glandular  en- 
largement, comparable  to  the  swelling  of  the  inguinal  and  iliac  glands  in  hip 
disease  ;  in  otljer  cases  the  supra-condyloid  gland  suppurates.  When  the 
olecranon  is  the  seat  of  the  primary  lesion  the  sinus  is  usually  over  it  and 
leads  directly,  or  nearly  so,  down  upon  it. 

In  old  neglected  cases,  the  number  of  sinuses  is  sometimes  considerable, 
and  the  soft  parts  are  undermined  and  much  destroyed  by  pulpy  infiltration. 
The  joint  is  kept  slightly  fle.xed,  and  there  is  usually  much  muscular  wast- 
ing. Occasionally  we  think  the  disease  begins  in  the  olecranon  bursa,  which 
is  so  common  a  starting-point  for  mischief  in  older  patients  ;  this  bursa  is 
sometimes  chronically  enlarged  in  children.  Stiffness  is  an  early  and  marked 
feature  of  disease  of  this  complex  joint,  though  the  mobility  of  the  fingers 
is  good,  even  if  there  is  much  infiltration  of  the  muscular  attachments  about 
the  elbow. 

Case. — Joseph  L.  D. ,  age  3  years  11  months;  admitted  January  27,  1882.  Left 
elbow  injured  b)'  a  fall  in  April  1881  ;  had  been  swollen  ever  since.  On  admission, 
liealthy-looking  child  ;  the  left  elbow  was  flexed  and  the  hand  semi-pronated  ;  very  little 
mobility  ;  two  sinuses  at  the  upper  and  back  part  of  the  joint  led  down  to  rough  bone  ;  a 
little  tenderness,  but  no  pain  ;  general  swelling  all  round  the  joint.  February  2,  the  joint 
was  excised  ;  disease  primarily  synovial ;  cartilage  diseased,  especially  on  head  of  radius  ; 
operation  not  antiseptic  ;  the  limb  was  put  upon  an  angular  splint.  On  the  13th  passive 
motion  was  begun.  On  March  i  passive  movement  could  be  carried  through  the  full  range 
in  all  directions,  and  there  was  a  little  power  of  active  movement ;  the  wound  was  nearly 
healed  ;  discharged.  October  3,  1882,  at  out-patients'  ;  elbow  quite  healed  ;  had  almost 
perfect  range  of  mobility  in  every  way,  and  the  arm  was  strong  ;  he  could  lift  a  chair 
with  it. 

The  "Wrist  Joint  is  perhaps  even  more  rarely  affected  with  tuberculosis 
than  the  shoulder,  but  in  children  we  have  on  three  or  four  occasions  had  to 
excise  the  j/aint ;  in  all,  the  wrist  joint  itself,  as  well  as  the  whole  carpus,  was 
disorganised,  the  disease  having  spread  among  the  synovial  sacs.  In  one 
instance  the  mischief  began  in  the  base  of  the  second  metacarpal  bone,  in 
the  others  the  starting-point  was  apparently  synovial.  In  two  of  the  cases 
an  excellent  result  followed,  the  whole  of  the  carpus,  the  bases  of  the 
metacarpal  bones,  and  the  lower  ends  of  the  radius  and  ulna  having  been 
removed  by  a  single  median  dorsal  incision  between  the  tendons  of  the 
extensor  indicis  and  the  extensor  secundi  internodii  pollicis  ;  no  tendon  was 
cut  through,  though  necessarily  those  attached  to  the  parts  removed  were 
stripped  back.  In  both  of  these  cases  a  nearly  perfectly  mobile  joint  was 
obtained  with  almost  full  mobihty  at  the  metacarpo-phalangeal  articulation 
— the  point  of  greatest  difficulty  in  disease  of  the  wrist. 

Case. — Disease  of  Wrist  Joint. — Annie  E. ,  age  6  years.  Admitted  March  25,  1885. 
History  unimportant.  No  cause  known  for  swelling  of  left  wrist,  which  began  six  months 
before  admission  ;  much  pain  ;  poulticed  for  three  months.  On  admission,  a  strumous- 
looking  child  ;  on  palmar  aspect  of  left  radius  at  lower  end  is  a  sinus  ;  much  thickening 
round  wrist ;  fluctuation  in  front  of  carpus  ;  movements  of  fingers  perfect  ;  those  at  carpal 
joints  absent.  April  16,  whole  carpus  except  pisiform  bone  removed  by  longitudinal  inci- 
sion on  dorsum  ;  some  bones  broken  down  and  unrecognisable  ;  cavity  scraped,  and  drained 
through  palmar  sinus.     May  i,  wound  has  progressed  fairly  and  is  now  healing.     15th, 


666 


Diseases  of  the  Joints 


sent  home  ;  tube  still  in  wound  ;  arm  on  splint  ;  result  very  good  ;   a  strong  and  mobile 
hand  (fig.  145). 

One  patient  remains  sound  ;  the  other,  after  keeping  well  for  a  long  time, 
developed  tuberculous  teno-synovitis,  which  will  probably  cause  some  loss  of 
movement.  In  the  third  case  the  carpus  alone  was  taken  away,  with  an 
even  better  result.  The  operation  mentioned  is  practically  Langenbeck's  ; 
it  is  much  simpler  than  Lister's  method,  and  we  think  much  superior  to  it  : 
the  bones  which  are  not  already  softened  and  destroyed  shell  out  easily 

from  the  pulpy  material  in  which 
they  are  embedded.  The  position 
of  the  sinuses  in  carpal  disease  is 
inconstant,  but  the  general  appear- 
ance is  shown  in  fig.  145. 

Chronic  Tuberculous  Disease 
of  the  iinkle  is  much  less  frequent 
than  that  of  the  knee  ;  but  in  four 
years  we  had  43  cases  of  disease  of 
the  ankle  or  tarsus  admitted  as  in- 
patients at  the  Children's  Hospital. 
Of  these,  excluding  disease  of  the 
OS  calcis,  most  of  the  cases  were 
probably  primarily  synovial,  but  in 
the  tarsus  extension  of  disease 
around  the  small  bones  so  interferes 
with  their  nutrition,  and  so  readily 
spreads  to  their  interior,  that  in  late 
cases  there  is  always  moi'e  or  less 
destruction  of  bone.  We  can  only 
recollect  one,  or  perhaps  two  instances  of  primary  necrosis  of  the  astragalus 
setting  up  disease  of  the  ankle  joint  ;  but  it  is  much  more  common  to  find 
mischief  spreading  from  the  lower  epiphysis  of  the  tibia  to  the  joint. 

Except  the  posterior  calcaneo-astragaloid  joint,  the  anterior  calcaneo- 
astragaloid  and  its  continuation  the  astragalo-scaphoid  joints  are,  perhaps, 
the  most  commonly  affected  of  the  tarsal  articulations  ;  but  the  common  sac 
or  any  of  the  tarsal  joints  may  be  attacked  by  disease,  which  then  spreads 
from  one  joint  to  another.  Calcaneo-astragaloid  disease  is  very  frequently 
the  result  of  necrosis  of  the  os  calcis,  and  it  not  rarely  extends  upwards  to 
the  ankle  joint  itself 

Disease  of  the  ankle  joint  is  marked  by  swelling  at  the  back  of  the  joint, 
obliterating  the  hollows  on  each  side  of  the  tendo  Achillis,  and  then  spread- 
ing round  and  below  each  malleolus,  especially  the  inner  (fig.  146) ;  the 
front  of  the  joint  also  becomes  swollen,  and  acquires  a  peculiar  flatness  or 
squareness  of  outline  as  a  result  of  loss  of  salience  of  the  extensor  tendons. 
The  foot  is  usually  kept  with  the  toes  pointed,  at  other  times  it  is  dorsi- 
flexed  ;  the  leg  rapidly  wastes  ;  later,  sinuses  appear,  usually  above  or  behind 
the  malleoli.  It  must  be  remembered  that  disease  often  extends  from  the 
joint  into  the  sheaths  of  the  neighbouring  tendons,  and  in  such  cases  suppu- 
ration or  swelling  may  track  up  the  leg  or  along  the  foot  for  a  considerable 
distance  ;  the  general  conditions  do  not  differ  from  those  met  with  in  the 


145. — Tuberculovis  Disease  of  the  Wrist. 


Chronic   Tuberculous  Disease  of  the  Ankle 


667 


knee.  In  disease  of  the  tarsal  joints  the  foot  is  swollen  in  the  position  cor- 
responding^ to  the  affected  articulation,  and  movement  of  the  particular  joints 
may  be  painful.  This  is  not,  however,  a  very  trustworthy  symptom  in  tuber- 
culous disease,  though  of  much  value  in  acute  inflammation.  When  the 
common  sac  is  involved  the  foot  assumes  a  bulbous  look,  with  the  toes  pointed 
and  pressed  closely  against  one  another.  The  disease  often  spreads  beneath 
the  extensor  or  along  the  plantar  tendons,  and  gives  rise  to  widespread 
mischief  in   the    soft    parts,    so    that    a 

sinus    by    no    means    always     indicates  /  ,  / ' 

disease   of  the  nearest  joint.     The  arch  ^  j  ' 

of  the  foot  is  seldom  lost,  in  consequence 
of  the  resistance  of  the  rigid  structures  in 
the  sole  of  the  foot.  With  two  exceptions, 
the  disease  is  usually  primarily  synovial  : 
one  is  that  already  mentioned  of  caries 
or  necrosis  of  the  os  calcis,  which  often 
extends  to  the  calcaneo-astragaloid  joints  ; 
and  the  other,  that  it  is  common  for  dis- 
ease of  the  first  metatarsal  bone  to  extend 
backwards  to  the  joint  between  it  and  the 
internal  cuneiform. 

It  is  sometimes  difficult  to  be  sure 
whether  an  abscess  on  the  dorsum  of 
the  foot — the  most  common  situation  for 
pointing  in  tarsal  disease — is  connected 
with  the  joints  or  is  merely  peri-articular  : 
in  some  cases  pain  on  pressure  or  move- 
ment of  individual  joints,  localised  by 
pressing  back  towards  the  ankle  individual 
toes  in  turn,  in  others  swelling  over  some  particular  joint  or  in  the  sole, 
will  indicate  a  deep  lesion  ;  but  often  exploration  is  required  before  a  certain 
conclusion  can  be  arrived  at. 

Acute  simple  Serous  or  Suppurative  Synovitis  is  uncommon  in  child- 
hood except  as  the  result  of  injury  or  rheumatism  ;  any  joint  may  be  affected, 
and  the  symptoms  in  no  way  differ  from  those  seen  in  adults.  There  is 
swelling,  which,  being  due  to  distension  of  the  synovial  sac,  follows  its  out- 
Imes  ;  heat  and  pain,  with  immobility  and  some  constitutional  disturbance, 
are  also  present.  The  inflammation  commonly  subsides  readily  by  treat- 
ment with  splints  and  ice  or  evaporating  lotions,  and  leaves  no  ill  results. 
In  some  cases,  however,  usually  in  unhealthy  children,  or  where  there  has 
been  a  wound  of  the  joint,  suppuration  occurs  ;  all  the  symptoms  are  then 
greatly  aggravated,  any  movement  is  exceedingly  painful,  and  the  tempera- 
ture may  rise  to  I03°-I04°. 

The  acuteness  and  severity  of  the  symptoms  vary  much  in  these  cases  : 
in  one  instance  the  hip  joint  suppurated,  nearly  the  whole  thigh  was  occu- 
pied by  a  large  abscess,  the  head  of  the  femur  was  partially  destroyed, 
and  th,e  mischief  extended  to  the  knee  joint,  which  also  suppurated  ;  both 
joints  were  incised,  but  the  child  sank  and  died.  Pus  was  found  in  the  knee, 
with  superficial  erosion  of  cartilages  ;  the  synovial  membrane  was  thick  and 


Fig.  146. — Tuberculous  Disease  of  the 
Ankle  Joint. 


668  Diseases  of  the  Joints 

hypereemic,  the  thigh  was  infikrated  with  sero-purulent  fluid,  and  the 
acetabulum  was  granulation-lined. 

In  other  cases  there  is  a  thick  '  mucous '  discharge  and  the  cartilages  are 
not  destroyed  :  in  these  cases  incision  generally  results  in  recovery  with  a 
mobile  joint.  This  form  of  disease  most  commonly  occurs  in  children  under 
two  years  of  age,  and  is  met  with  in  the  knee — less  often  in  the  shoulder, 
elbow,  hip,  or  foot.  Somewhat  like  the  above-mentioned  catarrhal  inflam- 
mation of  joints,  described  by  Volkmann,  appears  to  be  a  form  of  painless 
purulent  exudation,  not  connected  with  pyeemia  or  epiphysitis,  which  has 
been  described  by  Atkin,  of  Sheffield. ^ 

Pyaemic  Joint  Disease  is  not  rare  in  children,  and  may  run  an  acute  or 
chronic  course.  The  articular  lesions  may  be  the  only  evidence  of  pyccmia, 
or  they  may  occur  in  conjunction  with  bone  or  visceral  abscesses.  Both 
forms  of  disease  are  exceedingly  dangerous,  though  neither  by  any  means 
always  fatal.  We  have  had  a  case  under  our  care  of  a  boy  aged  3J  years, 
who  had  pneumonia  after  measles,  and  subsequently  suppuration  in  one 
shoulder  and  one  knee,  with  effusion  into  one  of  his  ankles,  and  double  em- 
pyema, together  with  abscesses  in  other  parts  ;  this  child  recovered  perfectly, 
with  a  mobile  knee,  though  with  a  somewhat  stiff  shoulder.  Effusion  into  a 
joint  in  pyaemia  is  not  always  purulent,  nor  does  the  presence  of  pus  in  a 
joint  or  elsewhere  always  demand  incision  and  drainage  \  the  effusion  may 
be  absorbed,  or,  after  aspiration,  may  not  recur,  and  on  examination  the 
articular  cartilage  may  be  found  quite  smooth  and  healthy,  or  only  somewhat 
yellow  and  opaque.  In  other  cases,  however,  the  cartilage  becomes  necrotic, 
or  it  may  rapidly  melt  away  entirely  or  in  patches,  leaving  the  articular 
lamina  of  bone  smooth  and  bare  ;  this  is  perhaps  the  most  typical  condition 
of  acute  pyEemia. 

Exantbematous  Synovitis,  or  that  form  of  joint  disease  which  occurs 
in  connection  with  the  specific  fevers,  has  already  been  alluded  to  in  discuss- 
ing those  affections,  and  scarlatinal  synovitis  or  rheumatism  has  been  fully 
described  (p.  256).  A  second  variety  occurs  generally,  but  not  always,  later 
in  the  course  of  the  fever,  and  usually  in  connection  with  severe  throat  lesions. 
The  affected  joint  suppurates  and  becomes  disorganised  ;  this  is  clearly  a 
pysemic  condition.  It  must  also  be  remembered  that  the  exanthems  are 
sometimes  a  determining  cause  of  the  appearance  of  a  tubercular  lesion. 
Typhoid  synovitis  is  rare,  and  is  said  to  be  almost  limited  to  the  hip  joint ; 
we  have,  however,  seen  the  knee  attacked,  and,  as  Gibney  has  pointed  out, 
the  spine  may  be  affected.  Synovitis,  probably  pyasmic,  occurs  as  a  rare 
complication  of  diphtheria.  An  exanthem  such  as  scarlet  fever  or  measles, 
occurring  in  the  course  of  a  joint  disease,  usually  gives  rise  to  suppuration 
and  rapid  destruction  of  the  joint  ;  in  some  cases,  however,  it  appears  that, 
as  in  the  .case  of  erysipelas,  the  more  active  inflammation  does  good  by 
causing  melting  away  or  absorption  of  the  chronic  inflammatory  material. 

'  Pathological  dislocation,'  i.e.  displacement  of  the  articular  extremity  of 
a  bone,  as  a  result  of  softening  of  ligaments  is  sometimes  met  with  in  cases 
of  exanthematous  synovitis,  and  we  have  seen  it  more  than  once  in  post- 
typhoid inflammation  of  the  hip  joint.     Both  hips  may  be  attacked  at  once. 

1  Brit.  Med.  Jour.  Jul)-  11,  1885. 


Syphilitic  Synovitis 


669 


Cbronic  Rheumatic  Artbritls  occurs  occasionally  in  children,  both  in  its 
polyarticular  (nodular)  and  monarticular  forms,  as  pointed  out  by  Charcot 
and  others,  and  we  have  once  or  twice  seen  it.  It  must  be  remembered 
that  such  cases  may  become  tuberculous,  and  we  have  seen  a  joint  which 
had  the  characters  of  chronic  rheumatic  arthritis  well  marked,  which  sub- 
sequently became  an  ordinary  pulpy  knee,  just  as  occurs  in  adults  ;  the  two 
conditions  may  be  seen  co-existing  in  one  joint. 

Case. — Chronic  Rheumatic  Arthritis. — Mary  Jane  E.,  age  13  years  ;  admitted  Feb- 
ruary 25,  1884.  No  rheumatic  or  gouty  history.  Duration  since  August  1882,  when  she 
had  pains  in  her  shoulders,  which  subsided  in  a  week.  Nine  months  ago  had  pain  in  left 
hip,  which  lasted  four  months  ;  then  the  left  knee  was  attacked  ;  both  were  swollen  ; 
no  other  joint  affected  ;  pains  worse  in  wet  weather  ;  not  increased  in  bed  ;  sweats  a  good 
deal  at  nights  ;  urine  often  contains  red  lithates.  On  admission,  well  nourished;  slight 
eczema  of  face  ;  heart  sounds  normal ;  right  knee  a  little  swollen  ;  no  crackling  or  thicken- 
ing ;  no  osteophytes.  Left  knee,  thickened  synovial  fringes  ;  well-marked  crackling;  edges 
of  both  condyles  distinctly  lipped.  Her  condition  improved  with  blistering  and  iodide  of 
potassium,  and  she  was  sent  out  on  March  15. 


Fig.  147.— Congenital  Syphilitic  Synovitis  of  both  Wrists. 

Syphilitic  Synovitis  is  occasionally  met  with  ;  we  have,  however,  only 
seen  a  few  cases  of  pure  synovitis  in  the  first  few  months  of  life  in  congeni- 
tally  syphilitic  children  ;  the  most  common  condition  is  syphilitic  telostitis. 
A  subacute  recurrent  syphilitic  synovitis  occurring  in  older  children  is  met 


6/0  Diseases  of  the  Joints 

with  ;  it  sometimes  rapidly  subsides  under  antisyphilitic  treatment,  as  in  the 
following  instance  ;  but  this  is  not  always  the  case — it  is  sometimes  rather 
intractable. 

Case. — Syphilitic  Synovitis  of  Knee.- — Jane  B. ,  age  S  years  3  months  ;  admitted  Octo- 
ber 31,  1882.  A  history  of  syphilis  in  the  brothers  and  sisters,  of  whom  there  have  been 
twelve,  seven  being  dead  ;  patient  herself  had  always  been  hearty  ;  two  years  ago  the  left 
knee  swelled  without  known  cause,  but  recovered  completely  in  fourteen  days  ;  the  eyes 
had  been  bad  since  May  1882  ;  the  right  eye  was  first  affected,  and  the  left  was  only 
attacked  three  weeks  ago  ;  has  not  had  much  photophobia  ;  the  left  knee  began  to  swell 
on  October  29  ;  she  had  a  good  deal  of  pain  in  it.  On  admission,  the  left  knee  was  much 
distended  with  fluid,  and  was  slightly  hotter  than  the  right ;  she  had  well-marked  inter- 
stitial keratitis,  which  was,  however,  subsiding ;  facial  aspect  and  teeth  also  characteristic  ; 
no  other  signs  marked.  Under  hyd.  c.  cret.  and  pot.  iod. ,  together  with  a  back  splint  for 
the  knee,  all  the  swelling  rapidly  subsided,  the  eyes  improved,  and  she  was  discharged, 
nearly  well,  on  November  21. 

Glutton  has  noticed  the  occurrence  of  symmetrical  synovitis  of  the  knee  in 
congenital  syphilis,  and  Gutterbock  ^  other  cases  of  asymmetrical  effusion  ; 
we  have  seen  the  same  thing  associated  with  periostitis  of  both  tibiae.  Gar- 
rington  and  Lane  record  a  case  of  suppurative  synovitis  of  the  hip,  knee, 
shoulder,  and  both  elbows  in  a  child  with  congenital  syphilis  ;  there  was 
rickets  also  present,  but  no  epiphysitis.'^ 

The  best  treatment  of  these  cases  is  the  administration  of  iodide  of 
potassium  in  full  doses,  as  children  take  it  well,  with  hydrarg.  c.  creta, 
while  mercury  ointment  should  be  rubbed  mto  the  part  affected  ;  if  there  is 
much  pain,  blisters  will  sometimes  give  relief.  Gonorrhoeal  rheumatism 
is  sometimes  met  with  in  children  in  association  with  vaginitis  or  ophthalmia 
neonatorum,  as  pointed  out  by  Glement  Lucas  and  others.  We  have  seen 
an  infant  a  few  weeks  old  in  which  a  stiff  flexed  wrist  remained  as  the  result 
of  what  was  described  as  '  erysipelas  of  the  hand.'  The  swelling  of  the 
hand  was  noticed  on  the  evening  of  the  day  the  child  was  born,  and  it  had 
also  purulent  ophthalmia. 

Acute  suppurative  Arthritis  of  Infants,  first  described  by  Sir  T. 
Smith,^  is  a  remarkably  well  defined  affection  of  fairly  frequent  occurrence. 
It  is  limited  usually  to  children  under  a  year  old,  though  we  have 
occasionally  seen  it  in  older  childi-en,  the  eldest  being  nearly  two  years  of 
age.  Pathologically  the  disease  is  an  acute  epiphysitis  leading  to  rapid 
destruction  of  the  ossifying  centre  of  the  bone  it  attacks,  with  perforation  into 
and  disorganisation  of  the  adjacent  joint.  In  one  instance  the  epiphysial 
nucleus  of  the  head  of  the  femur  was  found  lying  loose  in  an  abscess  cavity, 
or  rather  in  a  sinus  leading  from  the  joint.  A  large  number  of  the  infants  so 
attacked  die  of  pyaemia.  The  hip  is  the  joint  most  frequently  affected,  the 
knee  standing  next.  Of  ten  cases  of  our  own  the  hip  was  involved  in  eight 
instances — six  times  alone  ;  in  one  other  case  the  knee  was  involved  by  direct 
extension,  and  in  another  the  wrist,  shoulder,  and  hip  were  implicated.  In 
two  instances  the  disease  followed  whooping  cough,  in  one  it  came  on  after 
an  injury,  and  in  one  some  evidence  of  the  onset  of  the  disease  in  utero  was 

1  Rev.  Mens,  des  Mai.  de  I' Enfance. 

-  Brit.  Med.  Jour.  January  1885.     Path.  Soc.  Trans.  1885. 

5  Morrant  Baker,  John  Poland,  and  one  of  the  present  writers,  as  well  as  others,  have 
also  contributed  to  the  literature  of  the  subject. 


Acute  Suppurative  Arthritis  671 

obtained.     We  have  adopted  Sir  T.  Smith's  view  that  the  lesion  is  primarily 
epiphysial ;  and  it  is  so  certainly  in  the  majority  of  cases,  but  in  one  or  two 
we  have  not  found  evidence  of  anything  more  than  synovial  disease  ;  these 
would  perhaps  rather  correspond  to  Volkmann's  '  catarrhal  synovitis  ;'  and, 
on  the  other  hand,  we  have  met  with  several  cases  in  which  the  abscess 
pointed  outside  the  joint,  the  cavity  of  which   was  not  involved.     In  one 
instance  the  lesions  were  secondary  to  a  cervical  abscess,  and  there  was 
epiphysitis  of  one  shoulder  and  a  peri-articular  abscess  of  the  other,  so  that 
sometimes  at  least  the  presence  of  an  abscess  about  a  joint  in  an  infant 
is  not  due  to  an  epiphysitis,  and  sometimes  it  is  not  an  arthritis.     Battle 
believes  it  to  be  usually  an  affection  of  the  end  of  the  diaphysis '  primarily. 
It  is  often  difficult  to  make  out  the  connection  between  the  abscess  and  the 
joint,  but  with  care  it  may  be  found  in  most  cases.     The  severity  of  the 
disease  varies  considerably  ;  in  some  instances  the  mischief  goes  on  for  two 
or  three  months,  in  others  it  is  fatal  in  a  few  days.     The  characteristic 
features  are  the  age  of  the  child  ;  the  existence  of  great  swelling  round  the 
affected  joint,  often  involving  nearly  the  whole  limb,  and  not  uncommonly 
'  flying  about '- — i.e.  one  limb  becomes   swollen  and  then  subsides,  then  the 
swelling  appears  in  one  of  the  other  limbs,  and  finally  the  disease  becomes 
localised  in  one  joint  only,  leaving  the  parts  first  attacked  uninjured.      This 
curious  feature  of  the  disease  perhaps  indicates  its  relation  to  pyaemia.       In 
acute  cases  there  is  much  fever,  but  there  may  be  little  rise  in  temperature 
in   the  more  chronic  ones.     We  have   seen  a  case  in  which  tubercle  was 
apparently  engrafted  on  a  case  of  '  acute  suppurative  arthritis  '  of  the  hip. 

The  symptoms  and  course  of  the  disease  point  to  thrombosis,  extending 
from  the  vascular  cancellous  tissue,  or  to  embolism,  but  we  have  not  verified 
this  condition  ^f  J'/  nwrtevi.  The  size  of  the  abscesses  is  sometimes  remark- 
able ;  in  one  case  the  whole  thigh,  from  the  hip  to  the  knee,  was  a  bag  of 
pus,  both  joints  being  involved. 

These  children  are  generally  much  prostrated  and  often  very  anaemic, 
worn  out  by  pain  and  rapid  outpouring  of  pus. 

Treatment  consists  in  early  and  free  incision  into  the  abscess,  opening 
the  joint  if  it  is  swollen,  and  keeping  it  well  drained.  Stimulants  and  abun- 
dant nourishment  must  be  given.  It  is  not  necessary  to  put  the  limb  in  a 
splint  in  infants,  but  it  is  a  good  plan  to  tie  it  up  in  a  pillow  so  as  to  keep  it 
steady  ;  there  is  little  or  no  fear  of  a  stiff  joint.  Probably  half  the  acute  cases 
die.  If  recovery  takes  place,  the  limb  is  usually  shorter  and  weaker  than  the 
other,  but  there  may  be  a  practically  perfect  recovery,  and  there  is  generally 
good  mobility.  We  have  several  times  seen  older  children  with  weak  limbs 
clearly  the  result  of  this  disease  in  infancy.  Arrest  of  growth  is  less  likely 
to  occur  where  the  hip  is  involved  than  the  knee.  The  two  following  are 
fairly  typical  cases. 

Case.  — '  Acute  Suppurative  Arthritis'  of  Hip. — Alfred  W. ,  age  9  months  ;  admitted 
Mav  3,  1884.  History  good  ;  never  very  strong  ;  no  known  cause  ;  swelling  about  hip 
one  month  ago.  On  admission,  pale,  but  not  thin  ;  abscess  round  right  hip  ;  grating  felt 
in  joint.  Incision,  head  of  bone  gone.  5th,  takes  food  well ;  much  discharge  ;  temperature 
subnormal.     Did  moderately,  but  on  15th  still  looked  pale  and  ill.     Sent  home  on  24th 

1  Brit.  Med.  Jour.  May  9,  1891. 


6/2  Diseases  of  the  Joints 

with   wound   superficial.     Subsequently  fresh   suppuration   occurred,    but   after   a   hard 
struggle  the  limb  became  sound  and  well,  with  good  mobility  and  little  shortening. 

Case. — 'Acute  Suppurative  Arthritis'  of  Knee. — Mary  H.,  age  9  months;  ad- 
mitted March  21,  1885.  Family  history  good  ;  child  first  noticed  to  be  feverish  and 
restless  nine  days  ago  ;  the  knee  then  swelled  rapidly,  and  was  very  tender  ;  the  swelling 
is  now  less  than  it  was  a  few  days  ago.  On  admission,  a  well-nourished  child  ;  right  knee 
swollen,  hot,  tense,  and  shining  ;  fluctuation  felt  readily  ;  girth  10  in.  as  compared  with 
'j\  in.  on  the  left  side  ;  temperature  97'^.  Joint  freely  incised  on  outer  side,  and  a  quantity  of 
pus  escaped.  23rd,  swelling  gone  down  ;  a  fair  amount  of  discharge  ;  takes  food  well,  and 
sleeps  well  ;  temperature  101°.  April  i,  pus  tracking  upwards  and  inwards  ;  a  larger  tube 
inserted.  13th,  swelling  less  ;  doing  well.  May  2,  all  swelling  gone  ;  tube  removed,  nth, 
wound  healed  ;  all  well. 

Acute  Tuberculous  Synovitis  is  not  a  very  common  affection  ;  it  does, 
however,  occur,  and  rapidly  goes  on  to  suppuration  in  quite  young  children. 
The  most  typical  instance  we  have  seen  was  in  a  baby  ten  months  old,  in 
whom  suppuration  of  the  ankle  occurred  a  week  or  two  after  a  scald  over  the 
joint.  On  incision  a  few  drams  of  curdy  pus  escaped.  A  week  later  the 
child  died  of  pneumonia  and  was  found  to  have  generalised  tuberculosis  ; 
the  lungs,  liver,  kidneys,  spleen,  and  brain  were  all  affected.  Here,  from  the 
condition  of  the  tubercular  masses  in  the  brain,  it  was  clear  that  tuberculosis 
existed  at  the  time  of  the  injury  to  the  skin  over  the  ankle,  and  the  joint 
subsequently  became  tuberculous.  The  case  serves  to  illustrate  the  fact  that 
in  the  first  year  or  two  of  life  suppuration  occurs  as  a  result  of  inflammation 
more  readily  than  in  older  children.  Acute  tuberculous  disease  also  some- 
times follows  strains  or  fractures  in  the  neighbourhood  of  joints  ;  thus  we 
have  seen  advanced  pulpy  disease  of  the  elbow,  in  a  girl  of  eight  years,  nine 
days  after  an  injury  which  loosened  the  epiphysis  of  the  inner  condyle  of  the 
humerus.  The  following  case  is  also  noteworthy  as  an  illustration  of  the 
occasionally  acute  onset  of  the  disease  ; 

Q.x's.v.. — Acjite  Pulpy  Knee. — -Harry  A.,  age  3  years  9  months  ;  admitted  January  4, 
1885.  No  tuberculous  history ;  had  measles  at  two  years  of  age,  followed  by  whooping 
cough  ;  disease  of  knee  first  noticed  fourteen  days  ago  ;  no  cause  known.  _On  admission, 
stout,  well-nourished  boy  ;  right  knee  is  much  enlarged,  joint  hollows  obliterated  ;  swelling 
elastic,  no  distinct  fluctuation  ;  movements  very  limited  and  painful ;  right  knee  io|  in., 
left  knee  9  in.  ;  extension  applied,  i/th,  knee  straight ;  no  night  pain  ;  general  condition 
good.  2ist,  as  some  fluid  was  thought  to  be  present,  the  knee  was  aspirated,  and  two 
drams  of  sero-pus  drawn  off.  25th,  temperature  normal ;  general  health  good,  but  there 
is  still  fluid  in  the  joint.  February  4,  the  knee  was  enlarged  to  its  original  size,  a  Thomas's 
splint  was  applied,  and  he  was  sent  home.  Readmitted  April  29.  He  wore  the  splint  up 
to  readmission,  and  has  been  doing  fairly  well  till  lately.  On  admission,  the  swelling  has 
increased  to  11  in.  and  extends  some  distance  up  the  thigh  ;  the  veins  are  full,  and  the 
skin  tense  and  shining ;  the  patella  floats  ;  free  incisions  were  made  into  the  joint :  a 
large  quantity  of  turbid  serum  escaped  from  the  incision  on  the  outer  side,  while  from 
the  inner  one,  which  was  somewhat  lower  down,  pus  flowed  ;  operation  antiseptic  ; 
drainage  as  usual ;  the  wound  was  dressed  on  May  2  and  12,  when  there  was  not  much 
discharge  and  the  knee  was  quiet ;  temperature  never  above  99 '4°.  26th,  still  a  good  deal 
of  swelling ;  some  thick,  cheesy  pus  squeezed  out ;  the  knee  did  not  improve  much,  and 
on  June  29  he  was  taken  home  b}'  his  friends.  July  6,  readmitted,  knee  as  on  discharge. 
i8th,  temperature  102°  ;  some  retention  of  pus  on  inner  side  of  thigh  above  knee.  23rd, 
excision  of  joint ;  much  thick  pulpy  material,  cartilage  eroded,  but  surface  of  tibia  healthy, 
except  a  small  portion  at  the  inner  margin,  which  was  gouged  away ;  surface  of  femur 
bare  and  rough,  and  bone  soft  and  showed  several  points  of  pus  ;  when  gouged  the  bone 
was  quite  soft,  yellow  and  infiltrated  with  pus  ;  this  was  removed,  leaving  a  cavity  5  in. 


Treat nient  of  Ac?ite   Tubercular  Synovitis  673 

long  and  \  in.  deep  in  the  inner  condyle;  the  bone  surface  and  the  upper  synovial  cavity 
were  cauterised  with  the  thermo-cautery,  dusted  with  iodoform,  and  the  limb  was  put  up 
in  a  Howse's  splint  ;  wood-wool  dressing;  on  section  of  the  part  of  the  femur  removed 
a  yellow  caseous  mass  was  found  surrounded  by  soft  bone  ;  there  was  much  shock  for 
some  hours,  which  was  treated  by  opium,  warmth,  and  alcohol ;  did  fairly  well,  and  tem- 
perature was  never  above  ioo°  till  29th,  when  the  knee  was  dressed  for  the  first  time,  the 
temperature  having  run  up  suddenly  to  104''  (?) ;  wound  looked  well  and  was  quite  sweet ; 
pads  of  wood-wool  uniformly  soaked  ;  temperature  fell  and  was  not  above  ioi°  after 
30th.  August  3,  free  discharge,  doing  well,  but  splint  soiled  ;  it  was  removed,  and  replaced 
next  day;  union  seemed  firm.  8th,  tube  removed;  there  was  afterwards  some  trouble 
with  the  splints,  which  needed  changing,  and  the  wound  on  the  14th  was  no  longer  aseptic  ; 
the  tibia  became  displaced  somewhat  backwards  and  some  fresh  suppuration  followed  ;  this 
was  combated  by  making  him  lie  on  his  face  for  half  the  day  ;  he  slowly  improved,  and  on 
October  16  the  wounds  were  nearly  healed,  and  he  was  sent  to  Convalescent  Hospital. 
April  3,  1886,  one  sinus,  the  rest  of  the  wound  well  shrunk  ;  not  yet  firm,  but  in  good 
position  ;  fat  and  well. 

The  treat)nent  of  the  various  joint  affections  can  only  be  briefly  given 
here  ;  it  is  impossible  to  mention  all  the  applications  and  apparatus  that 
have  been  devised.  In  acute  7ion- suppurative  joint  affections  of  the  upper 
limb,  in  the  case  of  the  shoulder,  it  is  sufficient  to  strap  the  arm  to  the  side, 
or,  if  the  child  is  very  young,  to  bind  the  limb  with  a  flannel  bandage  across 
the  chest ;  lead  lotion  in  infancy  and  an  ice  bag  in  older  children  is  the  only 
further  application  required.  For  the  elbow  nothing  is  better  than  a  common 
inside  or  outside  angular  splint,  which  must  reach  from  the  axilla  to  beyond 
the  end  of  the  fingers  ;  all  short  splints,  leaving  the  wrist  and  fingers  free,  are 
obviously  insufficient.  For  the  wrist  a  straight  palmar  or  dorsal  splint  reaching 
from  the  elbow  to  beyond  the  finger  tips  should  be  appHed. 

For  the  hip  a  Bryant's  or  Thomas's  splint  should  be  put  on.  For  the 
knee  and  ankle  the  ordinary  back  splint  with  a  foot-piece  should  be  used, 
taking  care  that  when  the  knee  is  the  part  injured  the  splint  reaches  well  up 
to  the  buttock.  A  Thomas's  knee  splint  answers  excellently  for  all  stages  of 
knee-joint  disease,  but  the  child  must  of  course  be  kept  in  bed  for  acute 
affections  of'the  joints  of  the  lower  limb. 

When  suppuration  occurs  free  incisions  should  be  made  into  the  joint  and 
drainage  tubes  inserted  ;  where  there  is  no  previous  opening,  and  the  wounds 
are  aseptic,  washing  out  of  the  joint  may  be  employed,  and  the  wound  then 
closed  by  sutures  or  the  cavity  may  be  drained,  choosing  a  dependent  posi- 
tion for  the  incisions,  and  avoiding  the  dangerous  anatomical  area  of  each 
joint.  In  sub-acute  cases,  with  sero-purulent  fluid  or  even  pus  in  the  joint, 
aspiration  should  be  tried  once  or  twice  before  free  incisions  are  made  ;  but 
the  joint  must  not  be  allowed  to  become  distended  with  fluid,  since  this 
frequently  leads  to  subsequent  ligamentous  weakness. 

In  chronic  no7i-purulcnt  cffusio72^  and  in  cases  where  a  simple  synovitis 
has  left  thickening  behind,  elastic  pressure  by  a  Martin's  bandage  lightly 
applied,  or  by  common  bandages  applied  over  a  thick  layer  of  absorbent 
wool,  does  good  service.  Friction  is  often  useful,  and  blisters  frecpently 
relieve  pain  and  promote  absorption.  Care  must  be  taken  not  to  be  misled 
by  the  presence  of  adhesions  remaining  after  subsidence  of  disease  into 
thinking  that  progressive  mischief  exists.  A  joint  that  has  been  acutely  or 
subacutely  inflamed,  and  after  a  week  or  two  of  treatment  remains  stiff",  a 
little  swollen,  cold,  and  tender  on  pressure  over  one  or  two  spots,  with  intense 

X  X 


674  Diseases  of  the  Joints 

pain  at  perhaps  one  spot  on  any  rnoveniejit  beyond  a  ce7'tain  pointy  though 
movement  may  be  free  up  to  that  poi7it^  is  the  seat  of  adhesions,  and  requires 
breaking  down  of  these  bands  under  chloroform.  In  such  cases  inquiry- 
should  always  be  made  to  ascertain  that  there  is  no  evidence  of  any  tubercular 
taint  before  moving  the  joint.  After  breaking  down  adhesions  the  limb 
should  be  kept  quiet  for  twenty-four  hours  and  effusion  prevented  by  pressure 
or  cold  ;  and  then,  if  all  is  quiet,  both  active  and  passive  movement  should 
be  begun.  While  recognising  the  effect  of  adhesions  in  and  about  joints,  it  is 
well  to  remember  that  it  is  much  less  common  to  meet  with  cases  of  this 
kind  among  children  than  among  adults  or  adolescents  ;  probably  because 
the  restless  activity  of  childhood  prevents  the  joint  from  being  kept  still  after 
the  acute  and  painful  stage  is  over. 

When  a  joint  has  suppurated  no  premature  attempts  at  procuring  mobiHty 
should  be  made.  As  soon  as  the  joint  has  been  soundly  healed  for  a 
week  or  two  all  apparatus  should  be  left  off,  and  the  child  allowed  to  try  for 
itself — left,  in  fact,  to  do  as  it  likes,  in  reason — it  will  seldom  do  too  much. 
If  after  a  few  day^s  no  progress  in  mobility  is  being  made,  chloroform  should 
be  given  and  the  joint  carefully  examined.  It  is  generally  possible  to  make 
out  whether  the  adhesions  are  few  and  cordlike,  or  general  ;  in  the  latter 
case  a  permanently  stiff  joint  will  almost  certainly  result,  in  the  former  the 
adhesions  should  be  at  once  broken  down.  Where  a  stiff  joint  is  arranged 
for,  the  limb  must  for  many  months,  often  j^ears,  be  provided  with  a  splint  to 
keep  it  in  the  desired  position.     Children's  joints  are  very  slow  to  ankylose. 

We  have  no  great  belief  in  inunction  with  Scott's  ointment  or  oleate  of 
mercury,  and  painting  with  tincture  of  iodine,  as  modes  of  treating  chronic 
joint  lesions,  but  pressure  and  friction  are  invaluable  when  acute  mischief 
has  subsided. 

In  all  cases  of  synovial  tuberculosis  in  the  early  pre-suppurative  stages 
but  one  form  of  local  treatment  is,  we  believe,  of  much  value — absolute 
fixation,  with  or  without  pressure.  Where  there  is  acute  pain  or  a  subacute 
attack  in  the  course  of  chronic  disease  counter-irritants  in  the  shape  of 
blisters  or  the  actual  cautery  are  useful  to  relieve  the  pain,  but  we  do  not 
think  they  do  any  great  good  otherwise.  We  have  tried  and  given  up 
injections  of  iodine  and  carbolic  acid  into  the  pulpy  tissue,  and  we  cannot 
say  we  think  Scott's  dressing  is  of  any  great  use,  except  as  a  means  of 
pressure.  For  the  upper  extremity  the  plans  mentioned  for  acute  disease, 
combined  with  elastic  compression,  are  all  that  is  required ;  for  the  elbow 
and  wrist  the  splint  may  be  made  permanent  by  fixing  it  on  with  plaster  of 
Paris,  or  substituting  light  iron  strips  in  the  plaster  for  the  wooden  splint, 
or  a  poroplastic  splmt  may  be  used.  It  is  common  to  see  figures  of 
appliances  for  disease  of  the  elbow  and  wrist  in  which  the  fingers  are  left 
free  and  can  be  moved  ;  this  seems  to  us  opposed  to  all  principles  of  keeping 
the  joints  at  rest,  inasmuch  as  every  movement  of  the  fingers  must  necessarily 
disturb  both  elbow  and  wrist  joints.  The  joints  of  the  lower  extremity  must 
be  considered  more  in  detail. 

Injections  of  iodoform  into  tubercular  synovial  membrane  is  in  some 
cases  undoubtedly  followed  by  local  shrinking  and  cicatrisation  of  the 
tuberculous  material.  The  effect  is,  however,  very  local,  and  the  mode  of 
treatment  tedious  and  only  applicable  to  a  limited  number  of  cases. 


Tuhemdoiis  Disease  of  the  Knee  Joint  675 

Treatment  of  Tuberculous  Disease  of  the  Knee  Joint. — In  early 
stages,  where  there  is  no  dislocation  and  little  flexion  of  the  knee,  the  limb 
should  be  fixed  upon  a  back  splint  with  a  foot-piece,  and  as  long  as  the 
symptoms  are  acute  the  child  should  be  kept  in  bed.  If  there  is  much 
flexion  and  pain  the  limb  should  be  straightened  gently  under  chloroform, 
and  a  splint  then  applied  with  an  ice  bag  over  the  knee  for  the  first  twenty- 
four  hours  ;  where  there  is  flexion,  but  not  much  pain,  an  extension  should 
l^e  put  on  by  a  weight  fixed  with  strapping  below  the  knee,'  or  a  Macintyre's 
splint  may  be  used — we  prefer  the  weight.  As  soon  as  the  acute  symptoms 
have  passed  off  and  the  limb  is  nearly  straight — it  need  not  be  c^uite  so — a 
Thomas's  knee  splint  with  patten  and  crutches  should  be  provided,  and  the 
child  allowed  to  get  about  ;  if  there  is  much  thickening,  elastic  pressure 
should  be  employed  at  the  same  time.  Where  the  Thomas's  splint  cannot  be 
obtained,  or  the  friends  cannot  be  trusted  to  look  after  the  splint,  or  the  child 
is  too  young  to  use  crutches,  a  plaster  of  Paris  casing  should  be  put  on, 
strengthenedby  the  iron  strips,  as  shown  in  fig.  151.  As  Mr.  Paul  of  Liverpool 
has  suggested,  it  is  a  good  plan  to  cover  the  metal  with  rubber  tubing.  The 
child,  if  it  is  old  enough,  may  get  about  with  patten  and  crutches  after  the 
plaster  of  Paris  is  applied.  Children  under  four  years  of  age  cannot  usually 
be  trusted  to  use  crutches,  and  must  be  kept  off  their  feet  and  taken  out  of 
doors  in  a  perambulator  or  carriage.  Cod  liver  oil  and  iron,  careful  dieting, 
and  fresh,  above  all  sea  air — the  great  medicine  for  tuberculous  bones  and 
joints — should  be  the  general  treatment  where  possible.  As  long  as  there 
is  no  suppuration  a  fair  trial  should  be  given  to  the  plan  described  ;  it  is 
simple,  and  we  know  nothing  better.  There  must  be  no  taking  off  splints 
for  washing  or  to  see  how  the  joint  is  getting  on- — one  movement  of  a  joint 
may  undo  weeks  of  rest  ;  leather  and  lace-up  splints  are  for  this  reason  not 
so  good  for  hospital  patients  as  plaster  of  Paris,  though  we  greatly  prefer  a 
Thomas's  splint  where  it  is  possible.  Plaster  of  Paris  has  several  objections  ; 
it  is  messy  to  apply  and  impossible  to  keep  clean,  it  conceals  abominations 
of  all  soils,  it  is  apt  to  cause  sores,  it  is  heavy,  it  requires  periodical 
renewals,  it  is  prone  to  bring  about  a  chronic  venous  engorgement  of  a  part, 
which  makes  a  limb  flabby,  and  congested,  and  swollen,  and  ill  nourished, 
and  therefore  slow  in  repair.  In  spite  of  all  these  objections,  it  is  better  to 
put  on  a  plaster  of  Paris  splint  than  to  have  a  joint  imperfectly  kept  at  rest. 
Where  the  nurse  can  be  trusted  not  to  play  pranks  with  the  joint,  such  as 
allowing  the  child  to  bend  it,  or  stand  upon  the  limb,  washing  is  a  luxury 
that  may  be  occasionally  indulged  in,  but  fixation  comes  first.  If  in  spite  of 
this  treatment  the  joint  gets  worse,  operation  is  necessary  ;  but  in  the  case 
of  the  knee  a  very  large  proportion  of  jpatients  will  get  better,  and  this 
because  the  disease  is  mainly  synovial. 

When  a  joint  such  as  the  knee,  in  spite  of  efficient  treatment  for~two  or 
three  months,  steadily  gets  worse,  pain  and  swelling  increase,  and  the  child's 
health  begins  to  suffer,  more  active  means  must  be  taken,  and  these  will 
become  necessary  much  sooner  in  acute  than  in  chronic  cases.  If  the  pulpy 
material  is  rapidly  breaking  down,  and  suppurating,  and  yet  the  child's  health 
is  keeping  good,  success  is  sometimes  obtained  by  fixing  the  limb  'on  an 

1  One  pound  of  weight  for  each  year  of  the  child's  age  up  to  six  years  is  a  good  general 
rule. 

X  X  2 


676  Diseases  of  the  Joints 

interrupted  splint,  or  better  in  plaster  of  Paris,  and  then  opening  and 
carefully  draining  the  abscesses,  taking  care,  if  the  whole  joint  cavity  is 
suppurating,  to  drain  at  the  back  of  the  joint,  or  at  the  lowest  point  of  the 
abscess  sac  if  the  suppuration  is  localised.  By  this  means  a  certain  number 
of  these  children  will  do  well,  and  acquire  sound,  straight,  and  in  some 
instances  moA'able  limbs.  The  plan  is,  however,  only  exceptionally  appli- 
cable. If  there  is  no  suppuration,  but  the  pulpy  swelling  increases,  the  best 
mode  of  treatment  is  Erasion. 

Erasion,  or,  as  it  is  sometimes  called,  arthrectomy,  consists  in  the  case  of  the  knee  in 
opening  the  joint  freely  by  a  semilunar  or  other  incision,  just  as  in  the  ordinary  mode 
of  excising  the  knee ;  the  skin  is  reflected  and  the  capsule  removed  on  each  side  of  the 
patella  and  patellar  ligament,  or,  better,  the  patella  is  sawn  across  and  the  fragments 
turned  upwards  and  downwards  ;  if  necessary,  free  vertical  incisions  must  be  made  to 
reach  as  high  as  the  upper  limit  of  the  synovial  pouches.  It  is  well  not  to  dissect  up  the 
skin  from  the  underlying  tissue  more  than  can  be  helped,  as  the  pressure  of  the  dressing 
which  should  be  firmly  applied  sometimes  interferes  with  the  circulation  in  the  edges  of 
the  wound  and  delays  union.  Next,  every  particle  of  pulpy  granulation  tissue  is  carefully 
cut  away  with  scalpel  or  scissors  ;  all  the  infiltrated  capsule  and  the  semilunar  cartilages 
are  removed  and  the  articular  cartilage  scraped  quite  clean,  any  granulation  tissue  being 
carefull}"  picked  out  from  pits  in  the  cartilage,  and,  if  necessary,  any  foci  of  disease  in  the 
bone  gouged  away.  This  process  must  be  most  thorough,  and  extreme  flexion  of  the  limb 
is  required  to  fully  expose  and  clean  the  back  part  of  the  joint ;  the  crucial  ligaments  are 
scraped,  but  if  sound  preserved  ;  the  lateral  ligaments  are  divided.  The  upper  synovial 
sac  must  be  thoroughly  cleaned.  The  most  difficult  part  of  the  operation  is  getting  away 
the  posterior  part  of  the  semilunar  cartilages  and  the  synovial  membrane  at  the  back  of 
the  joint.  The  process  is  a  tedious  one,  often  lasting  one  and  a  half  or  two  hours,  includ- 
ing the  subsequent  putting  up  in  a  splint.  As  soon  as  all  bleeding  has  been  stopped  the 
limb  is  fixed  on  an  excision  splint  and  dressed  in  the  usual  method,  antiseptically.  Drain- 
age, if  used,  should  be  at  the  back  of  the  joint  on  each  side,  the  tubes  being  carried  through 
openings  made  behind  the  joint,  but  in  recent  years  we  have  used  no  drainage  and  closed 
the  wound  entirely.  When  this  is  done  it  is  important  to  arrest  all  bleeding  as  perfectly 
as  possible.  Usually  healing  throughout  by  primary  union  is  obtained.  We  prefer  to 
Esmarch  the  limb,  or  at  least  put  on  an  elastic  tourniquet  before  beginning  the  operation. 
We  usually  put  on  a  simple  interrupted  wooden  splint  at  first,  and  in  three  weeks  or  so  put 
on  a  Paul  or  Thomas's  splint.  For  a  series  of  cases  vide  Med.  Chron.  vol.  ii.  1885.  We 
introduced  the  operation  in  its  complete  form  in  January  1881,  and  the  first  case  was  that 
recorded  and  figured  below.  The  late  Mr.  Greig  Smith,  of  Bristol,  had,  however,  he  told 
us,  performed  the  same  operation  on  an  elbow  in  the  previous  year,  but  the  case  was  not 
published  until  after  our  first  case  was  recorded.  There  is,  however,  we  believe,  no  doubt 
that  Mr.  Greig  Smith  was  actually  the  first  surgeon  to  perform  erasion,  though  our  case 
was  the  first  published  and  his  was  unknown  to  us  till  long  afterwards.  We  desire  to  give 
him  full  credit  for  his  work. 

Case. — Lizzie  N. ,  age  13  years  9  months  ;  old  pulpy  disease;  joint  erased,  all  syno- 
vial membrane,  much  of  capsule,  semilunar  cartilages,  and  a  largish  patch  of  carious  bone 
removed,  as  well  as  a  good  deal  of  articular  cartilage  scraped  away;  result,  a  perfectly 
movable,  sound,  painless  joint,  used  as  freely  as  the  other ;  ligamentum  patelte  not 
divided.  She  was  under  observation  for  nearly  four  years  after  the  operation,  and,  except 
that  she  was  liable  to  occasional  serous  effusion  into  both  knees  as  a  result  of  overwork, 
she  remained  well.  The  knee  operated  on  differs  little  from  the  other  except  for  the 
presence  of  the  scar  across  it.  In  July  1889  this  patient  was  again  seen,  and  the  knee 
remained  perfectly  sound  and  mobile. 

Erasion,  we  think,  is  applicable  to  cases  of  fairly  early  disease  which 
have  resisted  efficient  treatment  by  splints,  &c.  Though  in  the  case  recorded 
we  obtained  a  freely  movable  joint,  we  have  never  had  such  a  perfect  result 


Erasion 


677 


since,  nor  do  we  think  it  wise  to  try  for  mobility,  except  in  a  few  instances 
where  the  wound  heals  at  once,  and  the  adhesions  are  few.  Erasion,  if  it 
fails,  leaves  the  limb  still  fit  for  excision  ;  where  it  succeeds,  the  limls  is  as 
sound  as  after  excision,  but  without  shortening. 

The  more  we  see  of  these  cases,  the  more  we  feel  sure  that  erasion  is  the 
proper  operation,  and  that  excision  is  hardly  ever  required,  while  the 
result  is  far  better  from  erasion  than  excision.  We  prefer  erasion,  as  above 
described,  for  the  knee,  but  the  general  rules  of  treatment  must,  of  course,, 
vary  with  the  particular  joints,  stability  and  absence  of  shortening  being 
the  cardinal  points  for  the  lower  limb,  mobility  for  the  upper.  Mere 
scraping  through  sinuses  is  of  but  little  use,  though  if  fistulae  exist  they 
should  be  well  cleared  out.'  Since  the  case  above  reported  was  operated  on, 
many  other  '  arthrectomies '  have  been  performed,  and,  on  the  whole,  with 


Fig.  148.  Fig.  149. 

Show  the  condition  of  Lizzie  N.  after  erasion,  and  the  free  mobility  of  the  joint. 

very  good  results.  Erasion  is  practically  the  only  operation  done  at  the 
Children's  Hospital  for  tubercular  disease  of  the  knee.  Excision  and  ampu- 
tation are  almost  unknown  there  for  this  joint.  We  have  read  many  articles, 
some  faintly  praising,  others  condemning,  the  operation,  and  a  few  cordially 
advocating  it.  We  and  our  colleague,  Mr.  Collier,  have,  provided  the  opera- 
tion is  properly  done,  seen  Tio  reason  to  be  dissatisfied  with  it,  and  can  only 
venture  to  suggest  that  failure  is  due  in  some  degree  to  incomplete  operations. 

Should  it  be  decided  that  the  case  is  too  far  advanced  for  erasion, 
excision  of  the  joint  should  be  performed.  We,  however,  have  so  seldom  of 
late  years  found  it  necessary  in  children  that  details  of  the  operation  need 
not  be  given. 

As  soon  as  the  anaesthetic  has  passed  off,  opium  should  be  freely 
1  Vide  Rev.  de  Chir.  March  188=;. 


6/8 


Diseases  of  the  Joints 


given.^  As  soon  as  the  wound  is  healed,  or  in  less  favourable  cases  as  soon  as 
only  sinuses  remain  open,  the  hmb  should  be  fixed  afresh  in  a  plaster  splint 
or  put  upon  a  Thomas's  splint,  and  in  about  two  months  the  child  may  be 
allowed  to  get  about  with  a  patten  and  crutches  ;  but  the  case  is  by  no 
means  done  with,  since  nearly  every  case  of  excision,  or  of  erasion  for  that 
matter,  of  the  knee  in  children,  unless  thoroughly  well  looked  after  and  a 
stiff  apparatus  kept  constantly  on  for  from  two  to  four  years,  according  to 
the  child's  age,  will  become  crooked.  Occasionally,  after  excision  of  the 
knee,  a  more  or  less  movable  joint  has  resulted,  but  we  do  not  look  upon 

this  as  an  object  to  be  aimed  at,  but 
rather  as  a  failure  of  the  operation, 
inasmuch  as  flexion  and  dislocation  are 
likely  to  result  where  no  bony  union 
is  obtained.  Flexion,  with  dislocation 
backwards  and  outwards,  is  the  com- 
mon deformity,  but  we  have  seen  a 
general  curve  of  the  limb  develop,  or 
distortion  at  the  epiphysial  line  of  the 
tibia.  This  deformity  is  one  of  the 
great  difficulties  and  drawbacks  in 
excision  of  the  knee  ;  the  operation 
itself  is  not  a  very  dangerous  one  : 
we  did  some  twenty-five  cases  in 
children  without  a  death,  though  some 
required  subsequent  amputation — this 
was  the  end  of  four  of  our  first  twenty- 
three  cases.  In  recent  years  we  have 
hardly  ever  excised  a  knee  ;  this 
operation  has  in  our  practice  been 
almost  entirely  superseded  by  erasion. 
The  amount  of  shortening  resulting 
varies  much  :  in  three  cases,  after  an 
interval  of  about  three  years,  it  ave- 
raged i^  inch.  Though  the  results 
after  excision  of  the  knee  are  neces- 
sarily imperfect,  it  must  be  remembered 
that  they  are  to  be  compared  with 
prolonged  suffering,  danger  to  life,  and  amputation  as  the  alternatives. 

Mobility  after  erasion  is  occasionally  accpired  and  may  be  perfect.  We 
are  doubtful  as  to  the  desirability  of  trying  to  get  it,  and  rather  prefer  to  let 
the  case  take  its  own  course  and  become  mobile  or  remain  stiff  according  to 
the  degree  of  perfection  of  the  joint.  Our  colleague,  Mr.  CoUier,  has  tried 
by  pei'sistent  movement  of  the  patella  to  obtain  a  more  mobile  joint,  but 
there  is  perhaps  hardly  time  yet  to  estimate  the  value  of  the  proceeding. 

In  neglected  cases  of  disease  of  the  knee,  even  though  the  disease  may 

have  to  a  great  extent  subsided,  the  joint  often  remains  flexed  and  subluxated 

to  such  a  degree  that  the  limb  is  nearly  or  quite  useless.     If  there  is  well- 

1  7TL  i  for  each  year  of  the  child's  age  is  the  usual  dose,  and  this  should  be  repeated  in 

an  hour  or  more  if  required. 


Fig  .150. — Shows  the  result  of  premature  use 
of  the  limb  after  excision.  The  operation 
had  been  done  at  another  hospital,  and  the 
patient  was  subsequently  admitted  under 
the  care  of  our  colleague  Mr.  T.  Jones. 
There  was  bony  ankylosis  in  the  position 
seen  in  the  figure, 


Deformity  from  Disease  of  Knee 


679 


marked  dislocation  backwards,  little  can  be  hoped  for  in  the  way  of  reduc- 
tion ;  all  the  tendons  and  ligaments  become  so  shortened  and  contracted 
that,  except  in  a  recent  case,  little  good  can  be  done  by  extension  or 
attempts  at  straightening — indeed,  in  some  cases  these  attempts  only  make 
matters  worse.  Where  there  is  flexion,  but  no,  or  only  slight,  displacement, 
extension  by  \\-eights  should  be  patiently  used  for  some  weeks  ;  if  no  result 
follows,  chloroform  should  be  given  and  an  attempt  made  to  straighten  the 
limb  by  forcible,  though  not  violent,  manipulations,  frequent  extension  and 
flexion  movements  being  employed  to  break  down  any  adhesions  in  or 
around  the  joint.  Should  it  be  clear  that  muscular 
contracture  is  an  important  factor  in  the  resistance, 
the  tight  hamstrings  should  be  divided,  but  we 
would  dissuade  from  any  violent  efforts,  especially  if 
there  has  been  much  suppuration  in  the  popliteal 
space  :  in  such  cases  there  is  much  risk  of  lacera- 
tion of  vessels.  Should  the  attempt  succeed,  the 
limb  is  brought  straight,  fixed  upon  a  back  splint 
for  a  day  or  two,  and  then  an  immovable  appa- 
ratus or  Thomas's  splint  applied.  Joints  will  often 
straighten  when  somewhat  flexed  and  even  when 
slightly  subluxated,  merely  by  prolonged  wearing  of 
a  Thomas's  splint. 

Should  it  be  found  impossible  to  straighten  the 
limb  by  these  means,  the  choice  lies  between 
excision  of  the  joint  and  osteotomy.  We  have 
employed  both  with  good  results,  but  they  are  ap- 
plicable to  somewhat  ditTerent  conditions.  Suppose 
the  joint  allows  considerable  movement  although 
it  cannot  be  straightened  sufficiently  to  be  of  use, 
osteotomy. is  likely  to  leave  an  unsteady  limb  ;  on 
the  other  hand,  an  acutely  flexed  limb  rec[uires 
removal  of  a  very  large  amount  of  bone  in  excision 
before  the  leg  and  thigh  can  be  brought  into  a 
straight  line.  We  think,  then,  that  osteotomy  is 
best  for  cases  of  stiff  joint  with  great  flexion,  excision 
for  those  where  there  is  more  mobility,  less  flexion, 
and   more   displacement.      The  late  M.  Beck  and 

B.  Pollard  advocate  division  of  the  crucial  ligaments  with  subsecjuent 
reduction  in  cases  of  subluxation,  and  have  recorded  a  few  cases  ;  we  think 
the  application  of  the  method  likely  to  be  limited,  since  division  of  these 
ligaments  certainly  does  not  allow  of  reduction  in  all  cases. 

Osteotomy  in  such  cases  is  not  a  difficult  operation  ;  a  longitudinal  in- 
cision is  made  about  three  or  four  inches  in  length  on  the  front  of  the  thigh 
from  the  patella  upwards,  the  femur  is  exposed,  and  a  sufficient  wedge  of 
bone  removed  from  its  anterior  surface  to  allow  the  limb  to  be  brought 
straight.  W'e  prefer  this  plan  to  simple  section,  which  may  cause  dangerous 
pressure  on  the  popliteal  vessels  and  be  followed  by  gangrene.  In  one  of 
our  cases  after  excision  we  could  not  nearly  straighten  the  limb  at  the 
time,  but  by  keeping  up  extension  after  the  excision  the  limb  was  gradually 


Fig.  151. — Splint  for  disease 
of  the  Ankle  and  Tarsus. 
It  is  made  of  iron,  covered 
with  india-rubber  tubing, 
as  suggested  by  Mr.  Paul. 
The  splint  is  fixed  to  the 
limb  with  plaster  of  Paris 
bandages. 


68o  Diseases  of  the  Joints 

brought  almost  straight.     The  following  case  illustrates  the  value  of  osteo- 
tomy in  certain  circumstances  : 

Case. — Necrosis  of  Tibia. — -Angular  flexio7i  of  Knee. — Osteotomy. — Ralph  H.,  age 
13  years  ;  admitted  January  12,  1885.  History  good  ;  well  till  two  years  ago  ;  complained 
of  pain  in  knee,  which  soon  swelled  ;  no  cause  known ;  twelve  months  later  had  some 
dead  bone  taken  from  the  leg  ;  discharge  has  continued  till  now.  On  admission,  well- 
nourished  boy  ;  was  sent  in  for  amputation  ;  the  left  tibia  is  enlarged  and  longer  than  the 
right  ;  on  the  inner  side  are  scars  of  former  operations,  and  a  large  sinus  over  the  upper 
end  of  the  bone  ;  the  leg  is  flexed  nearly  to  a  right  angle  ;  hamstrings  tense  ;  toes  pointed  ; 
foot  cannot  be  straightened.  24th,  has  had  6  lbs.  extension  on  since  admission,  but  the  knee 
is  no  straighter.  February  12,  has  had  on  a  Thomas's  knee  splint  since  last  note,  and  has 
been  getting  up  ;  no  improvement.  13th,  under  chloroform  an  attempt  was  made  to 
straighten  the  limb  forcibly ;  a  few  adhesions  gave  way,  but  no  sensible  improvement 
followed  ;  back  splint.  20th,  an  incision  3  inches  long  was  made  in  the  axis  of  the  femur 
above  the  knee,  the  periosteum  was  peeled  back,  and  a  large  wedge  of  bone  removed  with 
an  osteotome  ;  the  limb  could  then  be  nearly  straightened  ;  operation  antiseptic.  24th,  tube 
removed.  March  11,  limb  put  up  in  back  splint  with  movable  foot-piece  ;  wound  healed 
and  limb  straight.  20th,  fair  union  of  shaft ;  leg  straight ;  foot  in  good  position  ;  gets  up 
with  the  Thomas's  splint.  Sent  home  on  24th.  January  30,  1886,  leg  straight,  walks 
without  splint,  sound  and  well ;  toes  still  somewhat  pointed. 

In  another  recent  case  the  joint  was  much  flexed,  but  mobile  through  a 
certain  range  ;  on  excising  the  joint  it  was  found  impossible  to  straighten 
the  limb  without  greatly  shortening  it,  so  an  osteotomy  was  done  to  the 
junction  of  the  lower  and  middle  thirds  of  the  femur,  and  the  limb  was  then 
brought  into  good  position. 

Treatment  of  Pulpy  Disease  of  the  Ankle  Joint. — The  same  general 
rules  apply  to  the  treatment  of  tubercular  disease  of  the  ankle  as  to  that  of 
the  knee  in  the  earlier  stages  of  the  disease,  and  many  good  results  will  be 
obtained  by  simple  pressure  and  fixation.  To  carry  out  this  plan  the  best 
means  are  to  use  either  the  apparatus  shown  in  fig.  151,  or  a  short  metal 
back  splint  with  a  foot-piece,  the  child  being  allowed  to  get  about  with  a 
Thomas's  knee  splint.  Should  suppuration  occur,  and  the  joint  not  recover 
by  the  means  described,  the  prospect  is  a  somewhat  poor  one  :  however, 
erasion  and  resection  of  the  ankle  for  tubercular  disease  are  now  fairly 
satisfactory  operations,  though  the  disease  sometimes  spreads  and  amputa- 
tion is  required.  Amputation  is,  however,  in  these  days  almost  a  discarded 
operation,  except  at  the  hip  joint,  at  least  so  far  as  the  surgery  of  childhood 
is  concerned.  We  did  not  amputate  a  limb  at  the  Children's  Hospital  for 
joint  disease  during  three  years,  except  in  one  case  where  the  mischief  in  the 
knee  was  the  result  of  extension  in  a  case  of  acute  necrosis.  A  patient  trial 
of  fixation,  pressure,  and,  if  necessary,  repeated  removals  of  the  disease 
should  be  given,  even  after  suppuration  occurs,  provided  the  child's  health 
is  maintained,  but  the  prospects  of  such  cases  in  disease  of  the  ankle  are  not 
nearly  so  good  as  in  the  knee.  The  following  is  an  instance  of  a  satisfactory 
result  after  erasion  of  the  ankle  : 

Case.  — Peter  H. ,  age  8  years  8  months  ;  admitted  January  30,  1882.  Ten  weeks  ago  the 
right  ankle  became  swollen  ;  no  cause  known  ;  had  been  treated  with  cold  water,  strapping, 
&c.  ;  never  had  much  pain  in  it.  On  admission,  fairly  nourished  but  muddy-complexioned 
boy  ;  there  was  much  swelling  round  the  right  ankle  joint  on  all  sides,  with  increased  heat 
and  redness  on  the  outer  side,  but  little  or  no  tenderness  to  pressure,  though  movement 
of  the  joint  was  painful ;  the  circumference  was  an  inch  and  three-quarters  greater  than  the 
opposite  side  ;  the  position  was  semi-extended  and  rotated  slightly  inwards.     On  February 


Pulpy  Disease  of  Ankle  Joint  68 1 

9th  the  joint  was  opened  by  a  transverse  incision  (Mr.  Holmes's  plan)  across  the  front  of 
the  joint  dividing  all  the  extensor  tendons,  &c.  ;  much  pulpy  synovitis  existed  with  '  sub- 
chondral caries  ;  '  all  the  pulpy  tissue,  as  well  as  the  loosened  cartilages,  was  removed  as 
far  as  possible,  and  a  drainage  tube  passed  across  the  joint,  a  groove  being  cut  in  the 
upper  surface  of  the  astragalus  to  prevent  the  tube  from  being  nipped  ;  the  tendons  were 
then  stitched  together  with  catgut  and  the  wound  closed  ;  no  attempt  was  made  to  unite 
nerves,  and  the  anterior  tibial  artery  was  twisted  ;  sponge  pressure  was  applied  around  the 
joint,  and  the  operation  was  antiseptic  ;  finally  the  limb  was  fixed  on  a  back  splint  with  a 
foot-piece  ;  a  little  oozing  followed  at  the  first  dressing  ;  on  the  following  day  the  appear- 
ance of  the  foot- was  natural  below  the  line  of  incision;  a  little  superficial  ulceration 
occurred  at  the  outer  aspect  of  the  front  of  the  foot,  and  union  of  the  edges  was  slow,  but 
by  March  13  the  incision  had  healed  except  at  the  drainage-tube  openings  ;  no  pus  had 
been  discharged  up  to  this  date.  On  April  20  some  sensation  was  perceived  on  the  dorsum 
of  the  foot.  There  was  no  discharge,  and  on  May  28  he  was  sent  out  with  plaster  of 
Paris  over  an  Esmarch's  splint  and  a  sponge  dressing  still  applied  ;  after  this  progress  was 
ver)'  slow,  some  thickening  remaining  about  the  ankle,  and  occasionally  a  small  part  of 
the  cicatrix  would  ulcerate  and  break  down.  February  1885,  foot  sound  and  well,  but 
toes  are  somewhat  pointed,  and  he  '  throws  '  the  foot  in  walking.  He  gets  about  well  with 
a  boot  and  without  any  support.  A  good  deal  of  new  bone  formation  about  line  of  incision, 
but  some  mobility. 

We  have  also  had  some  excellent  results  after  excision  of  the  ankle. 

Case. — Disease  of  Right  Ankle. — Necrosis  of  Astragalus. — Richard  T.,  age  4  years 
5  months  ;  admitted  September  18,  1882.  Family  history  good.  History  :  Well  till  six 
months  ago,  when  the  ankle  began  to  swell  and  has  gradually  got  worse  ;  no  pain  ;  no 
injury ;  can  walk.  On  admission,  fairly  healthy  child  ;  somewhat  rickety  ;  right  ankle 
swollen  ;  bulging  on  each  side  of  extensor  tendons  and  round  each  malleolus,  especially 
on  inner  side  and  in  front  of  tendo  Achillis.  September  30,  ankle  joint  aspirated  ;  a  little 
serum  drawn  off,  and  some  tr.  iodi  injected.  October  20,  no  improvement ;  an  incision 
behind  the  inner  malleolus  gave  exit  to  two  teaspoonfuls  of  gelatinous  and  almost  melon- 
seed-like  material.  October  28,  wound  healed;  joint  refilled.  November  16,  tempera- 
ture rose  ;  i04'2°  on  i8th.  November  23,  joint  opened  ;  a  large,  loose  sequestrum  of  the 
astragalus  was  found  and  removed  ;  the  whole  astragalus  was  then  taken  away,  and  the 
lower  end  of  the  tibia  and  fibula  resected,  as  well  as  the  upper  surface  of  the  os  calcis  and 
the  inferior  tibio-fibular  joint.  The  joint  was  opened  by  a  transverse  incision  across  the 
front ;  the  tibial  and  extensor  tendons  were  stitched  together  afterwards.  Operation  anti- 
septic ;  sponge  pressure,  and  subsequently  salycylic  silk.  January  13,  antiseptics  left  off; 
had  been  doing  fairly,  but  slowly  ;  still  someswelling.  February  11,  sent  out  in  plaster  of 
Paris  over  an  iron  splint  round  foot ;  wound  not  healed.     He  finally  got  a  good  sound  foot. 

If  excision  is  performed  the  astragalus  should  always  be  removed  entirely 
and  all  tubercular  material  taken  away ;  there  is  then  a  fair  prospect  of  a  good 
foot,  and  only  when  this  fails  should  amputation  be  done.  The  prospects 
after  excision  are  much  better  now  than  they  were  before  recent  improvements 
in  the  management  of  such  cases.  We  have  had  some  very  satisfactory 
stumps  after  Pirogoff  s  operation,  and  watched  them  for  years  ;  and,  although 
it  occasionally  fails,  where  it  is  successful  it  gives  a  much  better  stump  than 
Syme's  amputation.  If  removal  of  the  foot  is  too  long  postponed,  disease  is 
apt  to  spread  up  into  the  tibia  and  along  the  sheaths  of  the  tendons,  and  then 
amputation  higher  up  the  limb  will  be  called  for  ;  but  the  question  of  ampu- 
tation, as  already  pointed  out,  very  rarely  arises.  (See  also  Treatment  OF 
Tarsal  Disease.) 

In  cases  of  tubercular  disease  of  the  ankle  that  resist  treatment  by  other 
means  we  now  usually  excise  the  joint  ;  at  least,  we  open  the  joint  by  the 
method   described,  remove  the  astragalus  and  all  tuberculous  material  and 


682 


Diseases  of  tJie  Joints 


close  the  wound.  The  results  are  most  satisfactory.  Care  must  be  taken 
to  avoid  over-extension  of  the  foot  (pointing  of  the  toes),  but  this  is  the  only 
difficulty  likely  to  arise.  As  in  the  case  of  other  joints,  amputation  is  the 
rarest  of  operations. 

Treatment  of  Tarsal  Disease. — It  has  already  been  pointed  out  that, 
except  in  the  case  of  the  os  calcis,  disease  of  the  tarsus  is  usually  synovial 
in  origin,  hence  it  should  be  treated  on  the  general  principles  of  such  lesions 
— absolute  fixation  of  the  foot,  with  entire  rest  from  any  strain — and  the 
usual  hygienic  means  should  be  employed  in  addition.  The  apparatus 
already  referred  to  for  disease  of  the  ankle  is  the  best  means  with  which  we 
are  acquainted  of  carrying  out  this  plan,  and  to  it  a  patient  trial  should  be 
given.  Should,  however,  this  treatment  fail,  complete  removal  of  the 
disease  by  operation  is  required.  Amputation  is  practically  never  necessary. 
It  is  impossible  here  to  fully  discuss  the  question,  but  the  conclusions  to 

which  our  experience  has  led  us 
are  these.  If  there  ai^e  definite 
sequestra  of  one  or  more  tarsal 
bones,  these  should  be  removed  ; 
the  fact  of  there  being  necrosis 
often  means  that  there  is  a  line 
of  demarcation  formed  and  re- 
covery may  follow.  It  cannot 
be  stated  absolutely,  because, 
as  already  pointed  out  in  the 
case  of  the  leg,  even  where 
sequestra  exist  tuberculous  in- 
filtration of  surrounding  bone 
may  be  present.  If  there  is 
general  synovial  disease  with 
caries,  it  is  best  to  freely  expose 
the  affected  parts  by  turning  up 
a  dorsal  flap  of  the  soft  struc- 
tures and  removing  the  diseased 
tissues,  but  so  long  as  any 
affected  synovial  membrane  or 
carious  bone  remains  recurrence  is  to  be  expected.  In  such  cases  the  best 
plan  is  total  resection  of  the  tarsus — i.e.  removal  of  all  the  tarsal  bones,  with 
or  without  the  exception  of  the  back  part  of  the  os  calcis,  which,  if  sound, 
may  be  left  to  form  a  support  for  the  heel. 

The  simple  transverse  dorsal  incision  turning  up  a  dorsal  flap  is,  we  think,  the  best 
method  ;  it  fully  exposes  the  parts,  the  divided  tendons  can  be  stitched  together  afterwards, 
and  the  use  of  the  foot  is  wonderfully  little  impaired.  After  the  operation  the  foot  may 
be  at  first  kept  merely  upon  a  back  splint  with  a  foot-piece,  but  as  the  cavity  begins  to  fill 
up  and  the  parts  consolidate,  the  iron  splint  (Paul's  splint)  vv-ith  plaster  of  Paris  forms  the 
best  appliance. 

By  this  method  excellent  results,  far  superior  to  those   obtained   by  a 
Pirogofif's  or  Syme's  amputation,  will  be  obtained  (fig.  152). 

Case. — Annie  E. ,  age  17,  sprained  her  foot  in  the  winter  of  1883-84,  and  came  under 
our  care  in  the  Ro)'al  Infirmary  in  November  1884.     She  was  then  a  fairly  healthy-looking 


^t-i.^..,j£;^^i- 


Fig.  152. — Shows  a  foot  after  resection  of  the  whole 
Tarsus  on  the  left  side  except  the  back  of  the  os 
calcis.     Annie  E.     Both  feet  are  flat. 


Tarsectomy 


ezi 


girl,  with  disease  of  the  anterior  calcaneo-astragaloid  and  astragalo-scaphoid  joints,  as 
well  as  swelling  of  nearly  the  whole  foot  ;  there  was  a  sore  below  the  inner  malleolus.  After 
treatment  by  rest  and  fixation,  part  of  the  astragalus  and  scaphoid  were  removed  in 
January  1885.  In  May  the  disease  was  still  progressing,  and  the  whole  of  the  tarsus,  with 
the  exception  of  the  posterior  part  of  the  os  calcis,  was  taken  awaj',  the  bases  of  the  meta- 
tarsal bones  and  the  malleoli  being  also  removed  ;  some  of  the  tendons  were  stitched  together, 
otherwise  no  attempt  at  adjustment  of  the  deeper  structures  was  made.  In  the  spring  of 
1886  the  foot  was  as  seen  in  fig.  152  ;  she  couid  '  spring'  upon  it  to  a  certain  extent ;  there 
vi'as  fair  mobility  and  power  ;  and  she  did  her  housework  with  no  other  support  than  a 
Martin's  bandage. — Vide  Med.  Chron.  September  1886.  In  1899  the  foot  still  remained 
sound.     We  have  had  a  good  many  similar  cases. 

Should  the  disease  recur,  amputation  may  possibly  be  required,  but  this 
is  far  less  likely  to  be  necessary  than  after  mere  gouging  or  scraping  opera- 
tions. Partial  resection  of  the  tarsus,  except  for  ?tecrosis,  is  rarely  successful 
— i.e.  where  there  is  mischief  spreading  about  among  the  tarsal  joints  it  is 
of  little  use  to  remove  merely  an  individual  bone  or  two  bones.  Unless  a 
clean  sweep  is  made  of  the  disease  it  will  probably  recur.  The  exception 
to  this  rule  is  the  os  calcis,  but  as  in  this  bone  the  disease  is  usually  central, 
it  stands  by  itself;  removal  of  the  entire  os  calcis  without  any  other 
bone  is  a  highly  successful  and  very  valuable 
operation,  and  is  often  called  for. 


Case. — Disease  of  Calcaneo-astragaloid  Joiiit. 
Caries  of  Os  Calcis.  Excision. — Norman  G. ,  age 
2  years  4  months  ;  admitted  June  11,  1883.  Family 
history  :  phthisical.  History :  measles  ten  months 
ago  ;  swelling  of  foot  followed  ;  has  been  under  treat- 
ment for  it.  On  admission,  sinus  in  sole  of  right  foot 
over  calcaneo-cuboid  joint,  another  below  outer  mal- 
leolus ;  much  thickening  about  os  calcis,  movement  of 
ankle  free.  June  14,  explored  ;  sinus  led  into  os  calcis, 
and  probably  to  calcaneo-astragaloid  joint  ;  drainage. 
July  7,  put  yp  in  plaster  of  Paris  with  ankle  splint  and 
discharged  ;  splint  had  to  be  removed  in  a  few  days 
on  account  of  swelling  ;  back  splint  put  on  ;  had  vari- 
cella July  II.  Re-admitted  July  24,  foot  worse;  dis- 
charge increased.  August  i,  flap  turned  forwards 
from  heel,  and  os  calcis  excised  ;  found  carious,  with 
a  large  cavity  ;  operation  sub-periosteal  ;  did  well ; 
discharged  August  25.  February  1884,  the  foot  healed 
and  become  sound  and  useful ;  a  small  fresh  collection 

of  pus  has,  however,  just  reformed  ;  the  os  calcis  has  been  largely  reproduced,  and  the 
foot  is  fairly  well  shaped.     May  1884,  sound  and  well ;  walks  excellently. 

The  treatment  of  tarsal  disease,  then,  is  rest  and  pressure  first  ;  failing 
this — and  it  should  have  full  trial — removal  of  sequestra  if  there  are  any  ; 
if  not,  resection  of  the  whole  tarsus,  or  at  least  of  such  part  of  it  as  shall 
include  all  the  joints  communicating  with  the  seat  of  disease.  Tarsectomy  for 
disease  is  not  practised  nearly  as  much  as  it  ought  to  be  in  spite  of  repeated 
advocacy  of  it  here  and  elsewhere.  It  is  a  successful  and  valuable  operation, 
and  has  in  our  experience  wholly  superseded  amputation  of  the  foot ; 
for  disease  of  the  os  calcis  removal  of  it  alone  is  the  better  plan,  and  when 
done  subperiosteally  there  is  usually  a  most  perfect  reformation  of  bone 
(fig-  153)- 


Fig.  153. — Shows  the  result  of  excision 
of  the  Os  Calcis.  There  is  nearly 
complete  restoration  of  the  bone. 


6184  Diseases  of  the  Joints 

After  total  resection  of  the  tarsus  we  much  prefer  to  keep  the  foot  in  its 
natural  position  and  allow  the  parts  to  adjust  themselves,  rather  than  arti- 
ficially produce  a  sort  of  equinus  foot  as  proposed  by  Wladimiroff.^ 

Disease  of  the  phalanges  and  metatarsal  bones  of  the  toes  differs  in  no 
way  from  the  corresponding  disease  of  the  fingers,  and  requires  the  same 
management  except  that  amputation  may  be  resorted  to  in  the  foot  earlier 
than  in  the  hand,  since  the  loss  of  a  toe  is  of  less  consequence  than  that  of  a 
finger. 

Disease  of  the  first  metatarsal  bone  and  of  the  metatarso-phalangeal 
joint  of  the  great  toe  is  common,  and  of  importance,  since  it  is  Hable  to  be 
followed  by  considerable  lameness.  Failing  rest  and  general  measures, .the 
question  of  amputation  or  resection  remains  ;  either  is  followed  by  a  certain 
amount  of  crippling,  but  resection  of  the  first  metatarsal  bone  is  so  frequently 
unsuccessful  that  the  most  speedily  satisfactory  result  is  probably  that  of 
amputation.  We  usually  resect  the  bone  as  a  first  resort,  and  only  amputate 
failing  this  ;  but  we  must  confess  that  even  when  resection  succeeds  the  toe 
is  so  shrunken  and  short  as  to  be  of  little  use. 

Sacro-iliac  Disease  is  not  very  rare  in  children  ;  it  is  usually,  we  think, 
the  result  of  extension  of  chronic  tubercular  disease  from  the  adjacent  bone, 
most  often  the  ilium — at  any  rate,  necrosis  is  common,  and  we  have  removed 
sequestra  which  included  the  articular  surface  of  the  ilium.  The  disease 
usually  runs  a  chronic  course,  and  gives  rise  to  comparatively  little  pain  ; 
often  attention  is  first  called  to  it  by  the  presence  of  an  abscess  over  the  back 
of  the  joint  ;  sometimes,  however,  the  matter  forms  at  the  intrapelvic  surface 
and  may  point  in  the  groin  or  track  down  behind  the  rectum  :  under  such 
circumstances  there  may  be  pain  down  the  leg  from  pressure  upon  the  sacral 
nerves.  Pain  is  sometimes  felt  in  walking  from  the  weight  of  the  body  bearing 
upon  the  diseased  joint,  and  pressure  directly  upon  the  joint  or  upon  the 
iliac  crests,  or,  again,  traction  upon  the  iliac  crests,  tending  to  draw  them 
backwards,  gives  rise  to  pain.  It  is  occasionally  possible  to  make  out 
mobility  of  the  ilium  upon  the  sacrum,  and  we  have  seen  displacement  of 
the  bones  as  a  result  of  disease.  Caries  of  the  spine  may  cause  sacro-iliac 
disease  from  the  burrowing  of  pus  into  the  joint,  and  in  most  of  the  cases  we 
have  seen  there  has  been  disease  of  bone  or  joints  elsewhere. 

Sacro-iliac  disease  is  best  treated  by  rest  in  bed  on  a  firm  mattress,  no 
sitting  up  being  allowed.  Should  an  abscess  form  and  increase  in  size  in 
spite  of  treatment,  it  should  be  opened  and  any  diseased  bone  removed  ;  as 
soon  as  the  acute  symptoms,  if  any  are  present,  have  passed  off,  the  child 
should  have  a  double  Thomas's  hip  splint  applied  :  he  may  then  be  moved 
out  of  doors  on  a  couch  with  safety.  If  the  position  of  the  abscess  prevents 
the  application  of  the  splint  in  the  ordinary  way,  the  apparatus  may  be  so 
arranged  that  on  the  affected  side  the  splint  is  applied  to  the  outer  side  instead 
of  to  the  back  of  the  limb  [znde  figs,  in  chapter  on  Spinal  Disease).  If  the 
child  recovers,  there  will  probably  be  some  arrest  of  growth  of  the  pelvis  on 
that  side,  and  a  lateral  curvature  of  the  spine. 

We  have  not  seen  a  case  of  acute  non-tubercular  sacro-iliac  disease,  and 
the  strength  of  the  articulation  is  such  that  any  acute  traumatic  mischief  is 
unlikely  to  be  met  with. 

1  A  paper  by  one  of  the  present  writers  in  the  Med.  Chron.  1886  may  be  referred  to. 


Disease  of  Teinporo-niaxillary  Joint  685 

Disease  of  the  Temporo-maxillary  Joint  occasionally  occurs  in  children 
as  the  result  of  scarlet  fevci",  injury,  or  necrosis  of  the  jaw  or  of  the  temporal 
or  malar  bones,  or  arises  by  extension  from  the  ear,  and  gives  rise  to  stiffness 
and  inability  to  open  the  mouth,  and  later  to  distortion  of  the  face  from 
arrest  of  growth.  Pain  in  movements  of  the  jaw  and  swelling  o\'er  the 
joint  are  the  usual  symptoms  ;  when  suppuration  occurs  it  usually  points 
over  the  articulation.  We  have  seen  the  joint  suppurate  in  a  case  of 
pyaemia  which  was  associated  with  acute  suppurative  arthritis  in  an  infant. 

The  treatment  consists  in  opening  the  abscess,  should  one  form,  and 
feeding  the  child  on  soft  food  ;  unnecessary  disturbance  of  the  joint  is  to  be 
avoided.  Should  the  jaw  become  stiff,  attempts  should  be  made  to  over- 
come the  stiffness  by  means  of  a  Maunder' s  screw,  used  several  times  daily 
after  forcible  opening  of  the  mouth  under  an  ansesthetic,  just  as  in  peri- 
articular adhesions  from  suppuration  in  the  neighbourhood  of  the  joint. 

Case. — Spurious  Ankylosis  of  Jaw,  with  Atrophy  of  the  Bone. — Thomas  C,  age 
8  years  4  months;  admitted  June  21,  1882.  Had  'low  fever  and  inflammation  of  the 
lungs'  at  two  years  old,  and  since  then  his  jaw  has  been  stiff,  so  that  he  lives  on  liquids 
and  sop  ;  was  thought  to  have  hydrocephalus  ;  soon  after  he  became  ill  he  had  otorrhoea, 
which  continued  until  the  time  of  admission  with  intervals.  On  admission  was  only  able 
to  open  his  mouth  about  a  quarter  of  an  inch  ;  nearly  all  his  teeth  were  carious  ;  he  spoke 
fairly  well  and  seemed  to  be  in  good  health  ;  the  jaw  was  much  atrophied,  so  that  the 
upper  teeth  far  overhung  the  lower  ;  the  jaw  was  forcibly  prised  open  under  chloroform, 
and  subsequently  JMaunder's  screw  was  used,  with  the  result  of  increasing  his  gape  to 
more  than  an  inch,  and  enabling  him  to  masticate  fairly  well ;  the  use  of  the  screw  was 
continued  up  to  February  1883. 

Failing  this  plan  one  of  the  forms  of  operation  for  the  establishment  of  a 
false  joint  should  be  performed  ;  probably  the  most  satisfactory  in  permanent 
results  is  resection  of  the  head  of  the  bone  by  an  incision  parallel  to  and 
below  the  zygoma,  taking  care  to  avoid  injury  to  the  facial  nerve,  but  we 
have  not  met  with  a  case  requiring  the  operation. 

Disease  of  the  Acromio-clavicular  and  Sterno-clavieular  Joints  is 
occasionally  met  with  ;  it  should  be  treated  by  fixation  of  the  arm  to  the  side. 
If  suppuration  occurs  the  joints  should  be  freely  opened  and  the  tuberculous 
material  removed.  We  have  found  sequestra  in  the  acromio-clavicular 
joint  {vide  Generai,  Surgical  Tuberculosis).  A  certain  amount  of 
disability  in  use  of  the  limb  may  result. 

'  Hysterical  Joints  '  {vide  chapter  on  HYSTERIA). — Though  the  utmost 
caution  must  be  used  before  deciding  that  any  joint  trouble  in  children  is  not 
due  to  organic  disease  provided  persistent  complaint  of  the  joint  is  made,  it 
is  an  unquestionable  fact  that  cases  of  so-called  '  Hysterical  joints  '  are  occa- 
sionally met  with.  W^e  have  seen  children  with  such  a  condition  affecting 
the  spine  and  more  rarely  the  hip.  The  great  clue  to  the  nature  of  the  case 
is  the  incompatibility  of  the  objective  signs  with  the  complaints  made  by  the 
child.  If  with  a  history  of  long-continued  complaints  there  is  no  local  evidence 
of  disease,  and  if  the  site  of  the  alleged  pain  is  inconsistent  with  the  known 
nerve  distribution,  and  if  also  the  pain  is  exaggerated,  we  should  carefully 
consider  the  possibility  of  a  '  neurosis,'  and  this  the  more  if  the  personal  and 
family  history  supports  such  a  view.  We  saw  in  1895  a  girl  of  about  twelve 
years  of  age,  who  a  fortnight  after  being  sent  to  work  complained  of  pain  in 


686  Diseases  of  the  Joints 

the  hip  and  subsequently  in  the  knee.  She  was  supposed  to  be  sufifering 
from  hip  disease.  On  examination  she  was  a  stout,  healthy,  but  excitable- 
looking  child.  She  walked  a  little  lame,  and  complained  of  pain  in  the  region 
of  the  anterior  superior  spine  of  the  ilium  and  in  the  knee.  There  was 
neither  swelling  nor  rigidity  of  the  joint,  but  alleged  great  tenderness  on 
pressure.  Further  examination  showed  that  pressure  on  various  other  points 
gave  rise  to  extreme  expression  of  pain,  but  by  leading  questions  complaint 
could  be  elicited  of  pain  in  other  parts  of  the. body  where  there  was  no  reason 
at  all  to  suspect  the  presence  of  disease.  The  complaints  were  incompatible 
with  what  we  know  of  organic  disease,  and  the  case  was  clearly  shown  to  be 
hysterical. 


68/ 


CHAPTER   XXXI 

HIP   DISEASE 


Hip  Bisease  ^  in  the  ordinary  sense  of  the  term — i.e.  tuberculous  disease 
of  the  hip  joint — is  almost  entirely  an  affection  of  childhood  ;  thus  only  T^ 
patients,  the  subjects  of  this  disease,  were  over  twenty  years  of  age  out  of  a 
total  of  619  cases  collected  by  ourselves,  and  probably  in  most  of  these  the 
disease  had  begun  in  an  earlier  age.  It  is  somewhat  more  commonly  met 
with  in  boys  than  girls,  and  is  much  more  frequent  among  the  poorer  than  in 
the  well-to-do  classes.  Mention  has  already  been  made  in  general  terms  of 
the  pathology  and  causation  of  the  disease  :  that  the  hip  may  be  taken  as  the 
joint  in  which  primary  tuberculosis  of  the  bones  forming  the  articulation  is 


Fig.  154. — -Diagram  showing  at  A,  A  (in  ver- 
tical shading)  the  parts  most  commonly 
afifected  in  Hip  Disease,  b  is  the  trochan- 
teric epiphysis.  The  lower  A  points  to  the 
'  calcar.'    (Altered  from  Barwell.) 


Fig.  155. — There  is  a  large  sequestrum  in  the 
neck  The  head,  which  is  still  cartilage- 
covered  but  is  almost  detached,  is  propped 
up  by  a  quill.  Vascular  perforations  are 
seen  in  the  marginal  cartilage.  Removed 
post  mortem. 


most  frequent.  Indeed,  our  own  belief,  based  mainly  upon  examination  of 
some  150  cases  of  excision  of  our  own,  is  that  in  true  chronic  morbus  coxae, 
such  as  we  ordinarily  see,  and  also  in  the  acute  and  rapidly  destructive  cases, 
the  disease  begins  almost  invariably  in  the  bone.  In  older  patients  a  primary 
synovitis  is  more  frequent,  but  in  children  an  acute,  subacute,  or  chronic 
inflammation  of  the  upper  epiphysis  of  the  femur  or  its  neighbourhood  is  by 
far  the  most  common  condition.  In  some  cases  the  disease  begins  in  the 
neck  of  the  femur,  and  when  this  is  so  it  is  generally  the  under  surface  that 
is  attacked,  and  this  is  the  part  on  which  the  greatest  strain  comes  in  injuries 

1  For  a  more  detailed  account  of  Hip  Disease  in  Childhood  than  space  allows  here 
the  reader  is  referred  to  the  monograph  by  one  of  the  present  writers  :  Hip  Disease  in 
Childhood,  by  G.  A.  Wright  (Longmans  &  Co.  1887).  Also  to  a  work  by  Dr.  R.  W. 
Lovett  of  Boston,  1892. 


688 


Hip  Disease 


applied  direct  to  the  trochanter,  and  also  the  part  least  abundantly  supplied 
with  vessels  (figs.  154  and  155). 

In  some  cases  the  disease  is  primarily  acetabular,  but  much  more  fre- 
quently the  initial  lesion  is  femoral,  though  rapid  destruction  of  the  acetabulum 
may  occur  secondarily.  In  one  hundred  cases  of  our  own  the  acetabulum 
was  necrosed  or  perforated  in  twenty-seven,  but  in  many  of  these  the  disease 
was  probably  primarily  femoral.  The  part  of  the  epiphysis  usually  first 
involved  is  the  immediate  neighbourhood  of  the  epiphysial  line.  The  occur- 
rence of  synovitis  of  the  hip  joint  is  not,  of  course,  denied  by  us,  but  we  believe 
that  two  entirely  different  classes  of  cases  come  under  observation  :  the  one  is 
a  simple  synovitis,  usually  traumatic,  a  lesion  that  occurs  in  the  healthy  and 
unhealthy  alike,  and  is  as  amenable  to  treatment  in  the  hip  as  elsewhere. 
The  other  class  is  one  composed  of  tuberculous  patients  ;  from  some  injury, 
or  even  slight  overstrain  only  of  the  part,  the  cancellous  tissue  of  the  bone 
has  its  normal  circulation  slightly  interfered  with  ;  inflammation  follows,  and 
inflammation  in  a  tuberculous  subject  is  only  too  prone  to  follow  the  usual 
course  of  a  tuberculous  lesion,  and  the  special  anatomical  features  of  the  hip 
joint  make  it  especially  liable  to  serious  and  progressive  disease.  Necrosis 
of  the  pelvis  or  femur  is  common  in  the  course  of  this  disease  ;  thus  in  our 
first  hundred  cases  of  excision  there  were  seventeen  instances  in  which 
sequestra  were  found,  either  in  or  detached  from  the  femur,  and  the  aceta- 
bulum contained  sequestra  in  twenty-two  cases. 


The  naked-eye  characters  of  a 
are  the  following  :  The  cartilage 


Fig.  156. — There  is  disease  on 
both  sides  of  the  epiphysial 
line.  On  the  under  surface  of 
the  neck  is  the  rough  depres- 
sion caused  by  pressure  against 
the  rim  of  the  acetabulum. 
There  was  pathological  dis- 
location. A  section  has  been 
made  through  the  upper  end 
of  the  femur. 


typical  specimen  from  hip  disease  in  an  advanced  stage 
is  all  gone  or  hanging  in  tags  or  worm-eaten  plates,  or 
it  may  be  merely  loosened  and  thinned  with  a  layer  of 
granulations  underlying  it  (fig.  156)  ;  the  synovial  mem- 
brane is  red  and  vascular,  somewhat  thickened,  but  rarely 
to  anything  like  the  degree  already  described  in  the  case 
of  the  knee  joint.  The  bone,  as  seen  in  section,  varies 
somewhat,  but  certain  characters  are  very  constant. 
Sometimes  the  whole  upper  epiphysis  is  detached  and 
forms  a  hard,  loose,  marble- like  sequestrum  ;  in  a  larger 
number  the  upper  epiphysis  is  destroyed  to  a  greater  or 
less  extent  :  sometimes  only  a  small  part  of  it  is  actually 
gone,  but  in  all  it  is  of  a  dull  yellowish-white  colour.  In 
some  late  cases  the  colour  is  opaque,  and  the  bone  is 
putty-like,  with  or  without  obvious  rarefaction  ;  in  earlier 
cases  there  is  a  mottled  appearance,  patches  of  dark  red 
hyperasmic  bone  alternating  with  dull  yellow  areas,  and 
here  and  there  a  soft  patch  of  granulation  tissue.  Se- 
questra maybe  present,  and  the  epiphysial  cartilage  may 
be  little  altered,  perforated,  or  entirely  destroyed. 


Occasionally  the  disease  spreads  far  down  the  shaft ;  more  commonly 
the  bone  below  the  level  of  the  great  trochanter  is  congested,  with  more  or 
less  rarefaction,  but  no  extensive  disease.  Corresponding  lesions  are  found 
in  the  acetabulum,  which  is  often  rough  and  eroded,  and  its  walls  absorbed, 
so  that  the  cavity  is  wider  and  shallower  than  in  health.  Occasionally  there 
is  very  extensive  caries  or  necrosis  of  the  pelvis,  and,  indeed,  nearly  the 
whole  innominate  bone  may  be  diseased.  It  must  be  remembered  that  even 
when  the  pelvis  is  perforated  there  is  a  thick  wall  of  dense  fibrous  material 


Hip  Disease,  witli  'travelling  acetabulum. 


Etiology  and  Pathology 


689 


intervening  between  the  pelvic  organs  and  the  joint  cavity,  so  that,  although 
the  bone  is  bare  on  both  aspects,  and  much  of  it  requires  removal,  there  is  no 
danger  of  injury  to  the  viscera.  The  joint  itself  usually  contains  pus  and 
false  membrane,  with  broken-down  caseous  granulations  and  detritus.  The 
conditions  commonly  found  in  the  acetabulum  have  been  already  mentioned  ; 
it  should,  however,  be  stated  that  in  the  later  stages  of  the  disease  what  is 
called  'travelling  acetabulum'  may  be  produced  where  repair  to  some  extent 
is  going  on  ;  the  rim  of  the  acetabulum  is  destroyed  by  what  looks  like  a  sort 
of  ploughing-up  process,  and  when  repair  begins  new  bone  is  formed  higher 
up  on  the  dorsum  of  the  ilium  to  form  a  socket  for  the  end  of  the  femur.  In 
some  instances  the  innominate  may  be  separated  into  its  component  bones, 
as  in  two  specimens  in  our  collection.     (See  fig.  I57-) 

In  other  cases  suppuration  may  occur  within  the  pelvis,  either  as  a  result 
of  perforation  of  the  acetabulum  or  of  extension  of  inflammation  through  the 
thickness  of  the  bone,  or  of  pus,  as  it  not 
unfrequently  does,  tracking  over  the  brim 
of  the  pelvis  and  then  gravitating  down- 
ward. We  have  seen  several  cases  where 
pus  has  burrowed  up  the  sheath  of  the  psoas 
and  so  got  within  the  pelvic  cavity. 

The  remains  of  the  head  of  the  femur 
may  lie  in  the  little-altered  acetabulum,  or 
be  drawn  upward  upon  the  dorsum,  or  even 
project  through  the  acetabulum  into  the 
pelvis  ;  it  has  been  found  fixed  to  the  ace- 
tabulum, though  quite  detached  from  the 
femur,  or,  rarely,  firmly  impacted,  as  we 
have  seen  it.  The  amount  of  acetabular 
disease  depends,  apart  from  the  possibility 
of  the  orgin  of  the  affection  there,  upon  the 
fact  that  when  once  the  joint  cavity  is  in- 
volved, a  large  surface — i.e.  the  whole  ace- 
tabulum— is  at  once  exposed  to  irritation, 
and  so  the  process  in  it  is  more  rapid  ;  it 
also  depends  upon  how  much  the  head  of 
the  femur  has  been  allowed  to  press  upon 
the  pelvis. 

It  is  very  rare  to  find  any  attempt  at  a 
new  formation  of  bone  while  the  disease  is  progressing,  while,  after  removal 
of  the  upper  end  of  the  femur,  new  bone  may  be  rapidly  formed  ;  in  this,  of 
course,  the  hip  resembles  other  joints.  The  rapid  formation  of  new  bone 
after  excision  is  a  strong  indication  for  that  operation,  in  that  it  shows  that 
nature  is  unable  to  begin  repair  until  the  disease  is  removed. 

The  etiology  and  pathology  of  morbus  coxse,  then,  may  be  summed  up  as 
follows  : 

I.  Hip  disease  is  dependent  upon  that  deficient  power  of  recovery  and 
tendency  to  caseous  degeneration  which  may  be  called  the  strumous  or  scrofu- 
lous, or,  better,  the  tuberculous  diathesis,  and  this  constitutes  the  predisposing 
cause.     The  disease  is,  in  fact,  a  local  tuberculosis. 

Y  Y 


Fig.  157. — Shows  extensive  Acetabular 
disease.  The  ihum  is  completely  de- 
tached from  the  other  two  bones,  and 
is  largely  necrosed  ;  white  scale-like 
patches  of  new  bone  are  seen  on  the 
surface.     The  disease  was  acute. 


690  Hip  Disease 

2.  Any  slight  or  severe  injury,  over-use,  &c.,  or  the  onset  of  a  specific 
fever,  may,  in  such  a  constitution,  prove  an  exciting  cause. 

3.  Injury  in  a  healthy  child  may  produce  synovitis,  or  even  acute  inflam- 
mation of  bone  about  the  hip,  as  elsewhere,  but  this  does  not,  except  very 
rarely,  lead  to  chronic  hip  disease. 

4.  In  the  vast  majority  of  the  cases  of  morbus  cox^  the  disease  begins 
as  an  osteomyelitis  of  the  upper  epiphysis  of  the  femur,  or  of  the  immediate 
neighbourhood  of  the  epiphysial  line,  or  not  very  rarely  of  the  acetabular 
epiphysis. 

5.  This  particular  osteomyelitis  tends  to  destruction,  and  usually  runs  a 
chronic  course  with  caseation  of  the  inflammatory  material,  and  resolution 
can  rarely,  if  ever,  be  expected  when  the  disease  is  well  established. 

6.  The  occurrence  of  the  disease  in  childhood  is  explained  by  the  physio- 
logical and  anatomical  peculiarities  existing  before  puberty. 

Besides  the  common  chronic  hip  disease,  there  is  a  form  of  acute  hip 
disease  which  may  run  its  course  in  a  few  weeks,  or  even  days,  and  produce 
as  much  or  more  destruction  of  parts  than  months  or  years  have  in  the  chronic 
cases.  Instances  of  this  condition  are  not  very  rare  ;  every  hospital  surgeon 
sees  them  occasionally.  Some  of  these  cases  are  probably  pysemic,  others 
belong  to  the  class  of  'acute  suppurative  arthritis  of  infants'  {vide  p.  670)  ; 
others,  again,  are  acute  traumatic  inflammation,  synovial  or  osteomyelitic  ; 
possibly  in  some  partial  separation  of  the  upper  epiphysis  may  occur,  with 
rapid  necrosis  ;  others,  again,  are  probably  cases  of  acute  periostitis  of  a 
nature  similar  to  that  occurring  in  the  shaft  of  the  femur,  tibia,  &c.  These 
last  may  result  in  widespread  suppuration  and  necrosis  of  the  pelvis  and 
femur.  An  acutely  destructive  condition  may  come  on  in  the  course  of 
chronic  disease. 

Lastly,  acute  tuberculosis  sometimes  leads  to  rapid  suppuration. 
Symptoms. — In  describing  the  symptoms  of  hip  disease  it  will  be  con- 
venient to  take  them  one  by  one,  and  discuss  the  views  and  explanations  of 
each  symptom  before  passing  on  to  the  next,  and  finally  to  group  them 
together  in  a  type  case. 

Pam. —  Pain  is  a  prominent  feature  of  most  cases  of  hip  disease  from  the 
beginning  ;  at  least  until  complete  disorganisation  of  the  joint  and  displace- 
ment or  destruction  of  the  head  or  recovery. 

The  seat  and  degree  of  pain  are,  however,  alike  very  variable.  Thus 
pain  may  be  referred  to  the  hip  itself,  the  buttock,  the  back  or  front  of  the 
thigh,  the  knee  in  front  or  behind,  or  any  part  of  the  leg  or  foot.  It  may  be 
localised  or  diffused,  so  that  the  patient  strokes  the  whole  thigh  down  in 
some  cases  when  asked  where  his  pain  is,  and  but  rarely  points  to  any  one 
spot.  There  is  no  consistent  relation  to  be  made  out  between,  the  seat 
of  pain  and  the  position  or  extent  of  disease.  Probably  the  front  and 
inner  side  of  the  knee  is  the  most  frequent  seat  of  pain.  Tenderness, 
however,  is  often  much  more  localised  to  the  position  of  the  joint,  but 
even  that  is  very  variable.  Pain  is,  undoubtedly,  often  remittent ;  some- 
times an  interval  of  some  weeks  intervenes,  even  without  treatment, 
between  the  attacks.  We  have  seen  cases  where  the  child  had  been  walking 
about  with  a  shortened,  distorted  limb,  who  never  had  any  pain  from 
beginning  to  end  ;  and  others,  with  large  abscesses,  who  have  also  been 


Pain  in  Hip  Disease  6gi 

throughout  free  from  pain  ;  while  the  agonising  pain  of  those  who  have  to 
endure  '  night  startings '  is  only  too  familiar  to  all  who  have  been  residents 
in  hospitals. 

In  considering  the  question  of  pain,  it-is  well  to  bear  in  mind  the  number 
of  different  sources  of  nerve  supply  to  the  joint. 

It  is  not  practicable,  nor  very  important,  to  distinguish  by  a  knowledge 
of  the  nerve  distribution  the  exact  patch  of  synovial  membrane  or  ligament 
that  is  locally  inflamed  :  its  only  value,  if  it  were  possible,  would  be  from  a 
prognostic  point  of  view  ;  but  here  history,  duration,  and  other  symptoms 
are  more  trustworthy.  There  is,  however,  no  doubt  that  '  night  pains '  give 
us  evidence  of  extension  of  the  disease  to  the  articular  surface. 

It  is,  then,  clear  that  pain  in  cases  of  hip  disease  is  variable  in  its  seat, 
or. rather  that  it  may  occur  in  a  great  many  different  places;  of  these, 
special  attention  has  always  been  paid  to  pain  in  the  knee,  and  several 
explanations  are  given  of  this  pain.  In  the  majority  of  cases  it  is  probably 
due  to  '  transferred  sensation '  from  one  of  three  sources,  the  anterior  crural, 
the  sciatic,  or  the  obturator  nerves,  branches  of  which  are  distributed  to  the 
front  and  back  of  the  joint.  In  our  experience,  the  pain  in  the  knee  is  generally 
rather  vaguely  referred  to  the  front  of  the  knee,  the  child  passing  its  out- 
stretched hand  over  the  whole  of  the  front  of  the  joint.  The  pain,  in  fact,  is 
referred  rather  to  the  distribution  of  the  anterior  crural  than  of  the  obturator. 

Pain  in  the  hip  is  not  usually  a  marked  sign  in  the  sense  of  there  being 
any  constant  pain  ;  tenderness  on  pressure  over  the  front  or  back  of  the 
capsule,  and  pain  in  pressing  the  trochanter  inward  or  the  head  of  the  bone 
upward,  is,  of  course,  present  in  all  acute  cases,  and  a  large  proportion  of  the 
chronic  ones. 

Night  starti?2gs  or  pains  are  a  prominent  and  important  feature  in  acute 
and  subacute  cases  ;  they  may  be  altogether  absent  in  chronic  disease — 
except  where  acute  mischief  has  supervened  upon  chronic — and  they  may 
be  absent  throughout  the  whole  course  of  a  case.  When  they  do  occur, 
they  indicate  that  inflammation  has  extended  to  the  joint  surfaces  ;  and 
further,  that  our  means,  whatever  they  may  have  been,  of  treating  the  lesion 
have  been  inefficient  so  long  as  these  startings  continue.  Their  cause  is  too 
well  recognised  to  need  discussing.  The  rigid  muscles,  acting  under  the 
influence  of  'joint  sense'  (Barwell),  contract  spasmodically  to  fix  and 
immobilise  the  joint  surfaces  ;  as  sleep  comes  on,  with  its  accompanying 
muscular  relaxation,  some  friction  or  pressure  of  the  tender  surfaces  together 
takes  place,  causes  acute  pain,  a  sudden  awakening  with  a  cry,  and  a  violent 
spasm  of  the  muscles  to  again  fix  the  joint.  This  may  be  repeated  many 
times  in  a  night,  and  is  a  strong  indication  for  treatment.  These  night 
pains  are  very  uncommon  after  excision  :  where  they  do  occur  they  mean 
that  disease  is  extending  in  the  pelvis,  and  probably  the  femur  is  not  kept 
sufficiently  far  away  from  the  acetabulum  to  prevent  pressure  upon  it ;  in 
such  cases,  then,  it  is  well  to  increase  the  extending  force,  though  in  some 
cases  too  great  extension  may  increase  pain.  Tenderness  or  pain  on 
pressure  has  been  already  alluded  to.  When  superficial  tenderness  really 
exists,  the  fears  of  the  child,  if  he  has  already  been  ungently  handled,  being 
taken  into  account,  it  means  that  suppuration  has  occurred  in  the  soft  parts 
and  is  becoming  superficial,  or,  in  very  acute  cases,  it  seems  that  really  all 

Y  V  2 


692  Hip  Disease 

the  parts  in  the  neighbourhood  of  the  joint  are  hypersesthetic  ;  it  is  certainly 
the  case  that  in  no  joint  does  inflammation  extend  so  widely  among  the  soft 
tissues  as  in  hip  disease. 

When,  however,  no  pain  is  produced,  except  on  deep  pi^essure  apjDlied 
over  the  head  of  the  bone,  it  is  probable  that  the  disease  is  limited  to  the 
bone,  and  has  not  yet  set  up  mischief  of  any  serious  nature  within  the  joint, 
or,  at  least,  that  any  such  change  is  a  very  chronic  one.  It  is  well  to  bear 
in  mind  that  pressure  on  an  inflamed  ligament  is  very  painful  indeed — a 
fact  easily  verified  in  chronic  synovitis  of  the  knee — and  it  is  possible  that 
the  pain  in  these  cases  may  be  due  to  extension  of  the  disease  to  the  capsule 
rather  than  to  the  inflammation  in  the  bone  itself. 

Certain  movements  of  the  joint  are  more  painful  in  case  of  inflammation 
than  others,  and  it  is  true  that  a  patient  may  have  quite  or  almost  painless 
power  of  flexion  of  the  joint,  and  yet  be  quite  unable  to  bear  rotation  or 
abduction. 

Night  startings  may  exist  and  be  due  to  hip  disease  without  any 
recollection  of  pain  on  awakening;  but  Howard  Marsh  cautions  us  against 
mistaking  the  cries  of  nightmare  for  those  of  night  starting. 

It  is  well  to  remember  that  inflamed  inguinal  or  iliac  glands  may  cause 
pain  and  tenderness,  which  must  be  distinguished  from  that  of  the  joint  itself. 
Lameness. — Limping  or  lameness  is  the  symptom  usually  first  noticed  by 
the  parents  in  the  case  of  children  with  chronic  hip  disease.  Even  this, 
however,  may  be  preceded  by  a  feeling  of  tiredness  or  ill-defined  aching 
about  the  limb  after  exercise,  the  aching  passing  off  after  rest,  but  recurring 
again  after  less  and  less  exertion.  The  limping  may  be  quite  painless  at 
first,  and  differs  in  appearance  from  the  well-marked  '  drop '  seen  in  later 
stages,  when  there  is  shortening  of  the  limb.  At  this  time  the  child  generally 
shows  a  tendency  to  rest  the  affected  leg,  and  throw  the  weight  upon  the 
sound  limb  at  every  opportunity.  Later,  well-marked  lameness  comes  on, 
and  is  accompanied  by  pain.  It  is  at  this  time  that  the  mistakes  in  diagnosis 
are  so  often  made  ;  the  obvious  symptoms  are  lameness,  and  often  pain  in 
the  knee  or  thigh  ;  there  is  no  other  marked  sign,  and  the  condition  is  sup- 
posed to  be  disease  of  the  knee  or  '  weakness '  with '  growing  pains,'  and  so 
on.  This  stage  requires  careful  and  exact  investigation  to  discover  it,  and 
at  the  same  time  is  the  period  at  which  treatment  is  most  effectual.  Later 
in  the  disease  lameness  is  due  either  to  actual  shortening,  or  to  tilting  of  the 
pelvis  to  take  the  strain  off  the  tender  limb,  or  to  flexion. 

Heat. — Increased  temperature  in  the  joint  is,  of  course,  only  perceptible 
where  the  inflammation  is  acute,  and  from  the  thickness  of  the  parts  cover- 
ing the  joint  is  not  readily  ascertained  ;  it  is  not,  therefore,  a  symptom  of 
much  value,  except  in  the  third  stage,  where  superficial  swelling  Combined 
with  heat  indicates  the  presence  of  suppuration  outside  the  joint.  In  some 
cases  of  acute  synovitis,  pure  and  simple,  a  local  rise  of  temperature  may 
be  made  out,  and  is  a  valuable  indication  of  acute  inflammation  of  the  soft 
tissues. 

Sivclling. — Swelling  is  one  of  the  most  important  symptoms.  In  the 
first  place,  local  swelling  over  the  front  and  back  of  the  joint — ^i.e.  just 
external  to  the  femoral  vessels  or  pushing  them  forward,  and  just  behind 
the  trochanter,  obliterating  the  normal  hollow — indicates  effusion  into  the 


Musailar  Spasm-  Rigidity  693 

synovial  sac,  and,  with  a  recent  history  of  injury,  indicates  an  acute  syno\'itis. 
With  a  longer  history  such  swelling  is  due  to  the  secondary  inflammation  of 
the  joint  by  extension  from  osteomyelitis. 

Swelling  of  the  great  trochanter  indicates  suppuration,  or  rather  caseation 
within  the  joint,  and  when  well  marked  we  believe  may  be  relied  upon  as 
pathognomonic  of  it  :  it  is  true  that  this  thickness  may  disappear  under 
treatment,  but  none  the  less  has  there  been  puriform  material  there  which 
has  been  absorbed  as  far  as  its  fluid  portion  goes,  and  if  once  that  thickening- 
has  occurred  we  do  not  think  any  case  is  free  from  danger  of  relapse.  This 
thickening  results  from  extension  of  the  disease  from  the  interior  of  the  bone 
to  the  surface. 

Periarticular  or  '  adjacent '  abscess  certainly  does  occur,  but  not  so 
commonly,  we  think,  as  some  writers  describe.  Swelling  of  the  inguinal 
glands  is  considered  by  Mr.  Barwell  to  indicate  osteitis.  We  would  go  e\-en 
farther,  and  say  that  when  considerable  it  often  indicates  disease  of  the 
pelvis  rather  than  of  the  femur.  It  is  common  to  find  some  enlargement  of 
inguinal  glands  in  tuberculous  children,  but  we  think  they  seldom  suppurate 
unless  the  pelvis  is  diseased.  The  condition  of  the  iliac  glands  will  be 
noticed  again. 

Muscular  Spasi/i. — .Spasm  of  the  muscles  around  the  hip  is,  as  in  the 
case  of  other  joints,  an  almost  universal  condition — quite  universal,  if  we 
except  those  cases  of  osteomyelitis  where  the  inflammation  is  as  yet  limited 
to  the  bone,  and  the  few  cases  where  the  joint  is  slowly  and  painlessly  dis- 
organised— cases  already  alluded  to  under  the  section  of  Pain. 

The  spasm  is  due,  as  is  well  known,  to  two  causes  :  reflex  spasm  from 
irritation  of  the  terminal  nerve  filaments  supplying  the  articulation,  the 
stimulus  being  reflected  in  accordance  with  Hilton's  laws  to  the  muscles 
moving  that  joint — Harwell's  'joint  sense  •'  and  secondly,  a  voluntary  con- 
traction of  the  muscles  to'  prevent  movement  of  the  painful  surfaces  the 
one  upon  the  other. 

It  is  well  known  to  what  the  particular  position  of  the  joint  in  disease  is 
due  ;  flexion  and  abduction,  as  long  as  it  remains  a  closed  cavity,  is  the 
position  of  least  tension,  and  thei'efore  of  least  pain  ;  the  aggregate  mass  of 
flexors,  too,  is  stronger  than  the  extensors  here  as  elsewhere,  so  that  flexion 
is  the  position  of  rest. 

The  rigidity  of  the  spasm  is  very  great  indeed,  so  much  so  that  in  many 
cases,  without  painful  manipulation,  it  is  impossible  to  say  from  mere 
physical  examination  that  the  joint  is  not  ankylosed.  In  most  cases,  how- 
ever, there  is  a  certain  limited  range  of  movement  allowed  through,  perhaps, 
10°  in  the  middle  of  flexion,  and  in  many  cases  a  considerably  larger  range, 
while  in  some  it  is  only  in  extreme  flexion  and  extension  that  spasm  exists. 
Nocturnal  spasm  has  already  been  alluded  to  under  the  section  of  Pain. 
Fixation  or  Rigidity. — Fixation  of  the  joint,  apart  from  muscular  spasm, 
may  depend  upon  an)'  one  of  three  causes,  but  can  only  exist  in  the  second 
or  third  stage  of  the  disease,  or  as  a  result  of  quiescent  or  cured  disease. 
The  causes  are  adhesions  within  or  around  the  joint,  matting  together  of 
muscles  so  that  their  power  is  lost,  or  bony  ankylosis.  Chloroform  at  once 
reveals  the  nature  of  the  rigidity,  whether  it  is  due  to  mere  muscle  spasm, 
when,  of  course,  it  will  disappear  ;  or  to  adhesion  or  permanent  muscular 


694  Hip  Disease 

contracture,  when  it  can  generally  be  sufficiently  overcome  to  show  that 
there  is  no  bony  union  of  the  parts. 

Grating  or  O^epitatioji. — Grating  felt  on  movement  of  the  hip  joint  can  be 
produced  by  one  cause  only,  the  presence  of  exposed  bone.  This  may  be 
due  either  to  erosion  of  cartilage  allowing  the  bare  head  of  the  femur  to  grate 
against  bare  acetabulum,  or  to  sequestra  grating  against  one  another,  or  to 
the  upper  end  of  the  femur  rubbing  against  its  own  bare  and  detached  head. 
It  is,  therefore,  where  it  can  be  felt,  an  absolute  and  pathognomonic  indica- 
tion of  the  presence  of  dead  or  carious  bone.  But  it  must  be  remembered 
that  it  can  usually  only  be  obtained  under  an  anaesthetic,  when  free  move- 
ment without  pain  can  be  procured. 

Abscess. — The  vast  majority  of  cases  of  hip  disease,  unless  seen  in  the 
early  stage  and  adequately  treated,  go  on  to  suppuration.  A  certain  number 
of  cases  get  well  by  the  process  of  removal  of  the  inflamed  end  of  the  bone 
without  suppuration — a  caries  sicca  ;  but  the  greater  number  by  far  go  on  to 
the  formation  of  pus.  Yet  of  this  number  by  no  means  all  develop  abscesses 
which  open  and  discharge  externally.  Suppuration  within  the  cavity  of  the 
joint  takes  place  and  even  bursts  the  capsule,  and  yet,  by  absorption  of  the 


Fig.  158. — Showing  the  extreme  Lordosis  produced  hy  partial  correction  of  the  deformity 
in  a  case  where  rectangular  flexion  existed. 

fluid  and  remo\'al  more  slowly  of  the  solid  elements,  the  swelling  caused  by 
the  abscess  may  disappear  and  the  case  recover.  Still,  we  are  convinced 
that  nearly  every  case  of  chronic  disease  of  the  hip,  if  not  cured  in  an  early 
stage,  would  be  found,  if  the  joint  were  examined,  to  contain  pus  or  purifoi'm 
liquid  at  a  certain  period  of  its  course. 

When  the  joint  cavity  suppurates  the  pus  may  take  very  various  courses 
after  it  has  burst  from  the  joint,  but  usually  it  issues  at  the  posterior  part, 
sometimes  on  the  inner,  sometimes  on  the  outer  side.  It  may  then  pass 
forward  beneath  the  rectus  femoris  and  point  at  the  anterior  border  of  the 
tensor  vaginse  femoris  ;  it  may  travel  down  the  thigh  and  point  at  a  lower 
part  of  the  edge  of  this  muscle  ;  it  may  gravitate  backward  and  open  at  the 
upper  or  jDOsterior  border  of  the  great  trochanter,  or,  farther  still,  at  the 
lower  border  of  the  gluteus  maximus  ;  it  may  reach  to  the  perinEEum,  extend 
along  the  adductor  tendons,  and  come  to  the  surface  at  the  inner  side  of  the 
thigh  ;  or,  again,  it  may  pierce  the  skin  just  at  the  inner  angle  of  the  fold  of 
the  groin  between  the  scrotum  or  labium  and  the  thigh.  It  may  travel  up 
the  sheath  of  the  psoas  and  point  'above  Poupart's  ligament,  or,  travelling 
over  the  brim  of  the  pelvis,  may  then  gravitate  downwards  and  burst  into  the 
rectum  or  the  ischio-rectal  fossa,  or  escape  through  the  sciatic  notch.  We 
have  records  of  two  cases  where  pus  was  discharged  through  the  rectum,  and 


J  Vastiug — Outline  69  5 

we  are  inclined  to  think  it  is  commoner  than  is  supposed,  and  that  the  dis- 
appearance of  abscesses  about  the  joint  is  sometimes  to  be  thus  accounted 
for.  A  bad  result  does  not  necessarily  follow,  and  some  cases  are  probably 
glandular  abscesses  not  directly  connected  with  the  joint  ;  in  other  instances 
fjecal  matter  has  been  discharged  into  the  joint. 

Abscesses  in  the  neighbourhood  of  the  hip  not  due  to  disease  of  that  joint 
must  be  carefully  distinguished  from  those  which  either  directly  communicate 
with  the  joint  cavity  or  result  from  the  breaking  down  of  tubercular  matter 
m  the  walls  of  the  articulation. 

From  the  cases  we  have  watched  we  think  the  conclusion  may  be  drawn 
that  when  an  abscess  points  on  the  front  of  the  limb,  above  a  line  drawn 
through  the  upper  border  of  the  great  trochanter,  there  is  disease  of  the 
pelvis,  and  this  is  the  more  certain  the  higher  and  the  more  internal  the 
.  opening.  Abscess  pointing  between  the  scrotum  and  labium  and  the  thigh  we 
always  look  upon  as  of  serious  import,  indicating  pelvic  caries.  The  peculiar 
conical  projection  to  be  felt  on  pressure  above  Poupart's  ligament,  as  pointed 
out  by  Barwell,  is  rather  due,  in  our  opinion,  to  enlargement  of  the  iliac  glands 
than  to  periosteal  pelvic  thickening  in  many  cases  ;  like  thickening  to  be  felt 
by  rectal  examination  at  the  site  of  the  acetabulum  on  the  inner  ^vall  of  the 
pelvis,  it  is  to  be  looked  upon  as  a  grave  sign  and  one  pointing  to  marked 
pelvic  disease,  and,  as  already  stated,  suppuration  of  glands  is  also  suggestive 
of  acetabular  disease. 

Wasting  of  Limb. — Muscular  wasting  of  the  affected  limb  is  an  early 
and  prominent  condition  in  hip  disease — so  early  and  so  rapid  that  it  is,  and 
with  good  reason,  ascribed  to  the  result  of  trophic  nerv^e  changes  rather  than 
to  mere  disuse.  The  limb  in  later  stages  assumes  a  peculiar  bulbous  look, 
the  thigh  and  leg  are  small,  thin,  and  weak,  while  the  hip  itself  is  rounded, 
swollen,  and  distended  as  compared  with  the  opposite  side,  and  coldness 
and  venous  congestion  are  commonly  present,  often  with  oedema  of  the  foot 
from  veneus  or  lymphatic  obstruction.  The  bone,  too,  undergoes  a  great 
amount  of  atrophy,  the  denser  layer  is  thinned,  and  the  spaces  of  the  cancel- 
lous tissue  enlarged,  so  that  the  bone  becomes  diminished  both  in  diameter 
and  strength.  Such  is  the  condition  which  has  in  several  cases  led  to  frac- 
ture of  the  bone  in  attempts  at  thrusting  the  upper  extremity  out  of  the 
wound  in  the  operation  of  excision,  and  this  is  a  fact  to  be  remembered  in 
the  forcible  straightening  of  the  limb. 

Arrest  of  growth  under  such  circumstances  is  to  be  expected,  and  does 
occur,  but  to  a  much  less  extent  than  would  be  imagined,  as  will  be  seen  in 
the  section  on  Results  of  Excision. 

OutH?ie  of  Region  of  Hip. — Two  points  are  always  described  in  con- 
nection with  disease  of  the  hip  as  being  characteristic  of  it — loss  of  the 
fold  of  the  groin,  and  flattening  and  widening  of  the  buttock  with  lowering 
and  partial  obliteration  of  its  fold.  These  conditions  are  worth  noting, 
although  they  are  not  always  present,  nor  always  characteristic  of  hip  disease 
when  they  are  present.  The  fold  of  the  groin  is  most  completely  obliterated 
when  the  limb  is  abducted  and  rotated  out,  especially'if  there  is  also  sweUing 
of  the  front  of  the  joint  or  glandular  enlargement.  On  the  other  hand,  the 
fold  is  exaggerated  in  adduction  and  rotation  inwards  ;  in  this  position  in  girls 
the  labium  will  be  compressed,  flattened,  and  partially  or  entirely  hidden. 


696 


Hip  Disease 


The  rima  Jiatium  is  inclined  upwards  and  towards  the  diseased  side, 
which  is  simply  the  appearance  produced  by  lowering  of  the  buttock  in  the 
second  stage  ;  in  the  third  it  of  course  takes  the  opposite  direction. 

Dislocatio7i  a7id  shortening. — The  older  writers  on  hip  disease  spoke 
of  dislocation  as  one  of  the  common  results  of  the  destruction  of  the  joint. 
Probably  they  were  misled,  in  the  absence  of  actual  dissection,  by  the 
shortening,  adduction,  and  inversion  of  the  limb  which  occur  in  the  third 
stage. 

As  a  matter  of  fact  it  is  probable  that  without  injury  true  dislocation  of 
the  head  of  the  femur  out  of  the  acetabulum  very  rarely  occurs.  Several 
conditions  may   exist  and  give   rise  to  the  appearance  of  dislocation,  the 


Fig.  159.— Shows  the  position  assumed  in 
the  second  stage  of  hip  disease.  Flexion, 
abduction,  rotation  outwards,  apparent 
lengthening.     Right  hip  disease. 


Fig.  160. — A  side  view  of  fig.  159. 


most  common  being  destruction  of  the  head  of  the  femur  ;  the  truncated 
upper  end  of  the  bone  is  then  drawn  upwards  by  the  muscles  attached  to 
the  trochanters,  so  that  the  upper  border  of  the  great  trochanter  rises  above 
Nelaton's  line  ;  here,  as  the  head  of  the  bone  no  longer  exists,  true  disloca- 
tion can  hardly  be  said  to  have  occurred.  Occasionally,  hoAvever,  true  dis- 
location of  the  head  of  the  femur  on  to  the  dorsum  does  occur — we  have  met 
with  several  instances  of  it. 

Apparent  lengthening  of  the  limb  is  due  to  a  lowering  and  throwing  for- 
ward of  the  pelvis  on  the  affected  side  ;  apparent  shortening,  on  the  other 
hand,  to  the  pelvis  being  raised  and  thrown  behind  the  sound  side.  Or,  to 
take  the  same  fact  in  another  way,  the  apparently  lengthened  limb  is  flexed 
and  abducted,   the  apparently  shortened  limb  is  flexed  and  adducted,  the 


Diagnosis  697 

two  conditions  being  usually,  but  not  always,  associated  with  rotation  out- 
ward and  inward  respectively. 

Taking  the  usual  classification  of  the  course  of  the  disease  into  three 
stag'es,  the  position  assumed  successively  by  the  limb  will  be — in  the  first 
stage,  flexion  to  a  variable  degree,  with  or  without  slight  abduction,  and 
possibly  rotation  outward  ;  in  the  second  stage,  flexion,  usually  well  marked, 
with  abduction  usually,  and  rotation  outward,  producing  apparent  lengthen- 
ing— sometimes,  however,  there  is  adduction,  and  sometimes  mere  flexion, 
with  no  rotation,  or  with  rotation  inward  ;  in  the  third  stage  there  is  always 
flexion,  and  most  commonly  adduction  and  rotation  inward,  with  apparent 
or  real  shortening,  but  there  may  be  abduction  and  rotation  outward.  Thus 
position,  though  a  valuable,  is  not  an  absolute  guide,  and  requires  to  be 
checked  by  the  only  symptoms  present. 

Diagnosis. — The  diagnosis  of  disease  of  the  hip  is  as  difficult  in  some 
cases  as  it  is  easy  in  others.  In  well-marked  cases  where  the  disease  is 
advanced  it  usually  is  quite  readily  diagnosed,  while,  on  the  other  hand,  few 
diseases  are  so  closely  simulated  by  a  large  number  of  other  affections  as 
disease  of  the  hip,  and  the  variety  of  symptoms  that  it  presents  is  in  itself  a 
fruitful  source  of  mistake.  It  will,  perhaps,  most  conduce  to  a  clear  under- 
standing of  the  subject  if  we  first  tabulate  the  diseases  for  which  hip  disease 
is  most  likely  to  be  mistaken. 

1.  Acute  rheumatism. 

2.  Bursitis  of  the  psoas  or  one  of  the  gluteal  bursae; 

3.  Ostitis  or  periostitis  of  the  great  trochanter. 

4.  Periostitis  of  the  upper  end  of  the  femur. 

5.  Sacro-iliac  disease. 

6.  Psoas  abscess. 

7.  Iliac  abscess. 

8.  Gluteal  abscess,  traumatic  or  spinal. 

9.  Abgcess  connected  with  disease  of  the  pelvis. 

10.  Perityphlitic  abscess,  suppuration  around  the  sigmoid  flexure  of  the 
colon,  pelvic  glandular  abscess,  or  chronic  adenitis,  or  possibly  renal  disease. 

11.  Superficial  abscess,  glandular  or  other,  and  deep  abscess  around  the 
ioint. 

12.  Infantile  paralysis. 

13.  Syphilitic  synovitis  or  telostitis. 

14.  Hysteria. 

15.  '  Congenital  dislocation'  of  the  hip,  or  other  congenital  conditions. 

16.  Rickets,  including  coxa  vara. 

17.  Disease  of  the  knee. 

18.  Fracture  of  the  neck  of  the  femur,  separation  of  the  upper  epiphysis 
or  dislocation. 

19.  Acute  synovitis. 

Of  these  diseases  only  a  few  of  the  more  important  need  be  selected 
here.  Inflammation  of  the  gluteal  bursee,  of  which  that  between  the  gluteus 
maximus  and  the  great  trochanter  is  the  most  commonly  affected,  may 
simulate  hip  disease.  In  this  case  a  large  gluteal  abscess  may  be  mistaken 
for  abscess  connected  with  the  joint,  or  if  the  abscess  has  burst  the  long 
track   left   may   lead   upwards,  and  be   indistinguishable   from    one   com- 


698  Hip  Disease 

municating  with  the  joint  ;  the  absence  of  shortening,  of  adduction,  or  of 
grating  on  movement  of  the  joint,  which  will  also  move  freely  through  a 
certain  range,  absence  of  pain  on  jarring  or  pressure,  and  of  fulness  in  front 
of  and  behind  the  joint,  are  the  diagnostic  points. 

Disease  of  the  great  trochanter  is  more  difficult  to  distinguish,  and  it  must 
be  remembered  that  inflammation  may  extend  from  the  shaft  to  the  joint ;  but, 
although  in  trochanteric  disease  sinuses  may  exist  in  the  same  positions  as 
those  in  which  they  are  found  in  morbus  coxee,  the  smoothness  and  freedom 
from  grating,  as  well  as  the  wide  range  of  mobility  of  the  joint,  will  serve  to 
distinguish  between  the  two  ;  other  abscesses  in  the  neighbourhood  of  the 
joint  are  recognised  by  their  history,  which  is  usually  too  short  for  chronic 
hip  disease,  and  not  acute  enough  or  sufficiently  severe  for  acute  joint  in- 
flammation. They  are  also  recognisable  by  the  freedom  and  smoothness  of 
the  movements  of  the  joint  through  a  certain  range,  even  though  that  range 
may  be  a  limited  one.  Absence  of  pain  and  tenderness  in  some  part  of  the 
joint  circumference  will  be  contributory  evidence. 

Infantile  paralysis  simulates  hip  disease  in  the  lameness  to  which  it 
gives  rise,  but  is  distinguished  from  it  by  the  absence  of  pain  and  swelling, 
and  especially  by  freedom  of  mobility,  and  by  an  amount  of  wasting  and 
coldness  of  the  limb  dispi^oportionate  to  the  other  symptoms,  as  well  as  by 
the  history  of  the  disease  ;  it  is,  however,  worth  noting  that  in  the  '  British 
Medical  Journal'  for  1877  Mr.  Savory  records  a  case  of  acute  hip  disease  in 
a  leg  affected  by  infantile  paralysis. 

Syphilitic  disease  is  distinguished  by  other  evidences  of  syphilis,  by  the 
slight  tendency  there  is  to  suppuration,  and  by  its  amenability  to  mercurial 
or  iodide  treatment.  We  have,  however,  seen  chronic  hip  disease  in  a  con- 
genitally  syphilitic  child. 

Sacro-iliac  disease  and  psoas  abscess  may  both  simulate  hip  disease  in 
regard  to  the  position  in  which  they  give  rise  to  pain,  and  as  to  flexion  of  the 
joint  ;  it  is,  however,  only  necessary  to  examine  the  spine  and  sacro-iliac 
articulations  to  find  in  most  cases  symptoms  incompatible  with  disease  of  the 
hip  alone,  while  in  simple  psoitis  flexion  and  inward  rotation  are  free. 

It  must  be  remembered,  at  the  same  time,  that  the  abscess  within  the 
psoas  sheath,  resulting  from  either  of  these  diseases,  may  open  into  the  hip 
joint,  and  so  a  secondary  hip  disease  may  be  developed.  It  is  not,  we 
believe,  very  rare  for  psoas  abscess  to  do  so ;  and,  although  we  have  only 
had  one  opportunity  of  verifying  the  fact  post  mortem,  we  have  in  several 
instances  believed  such  to  be  the  case.  Spinal  caries  and  hip  disease  may,  of 
course,  coexist  independently  of  each  other,  and  this  is  not  rare.  It  is  some- 
times impossible  to  be  sure  that  disease  of  the  hip  does  not  exist  where  an 
iliac  or  psoas  abscess  has  burrowed  down  and  surrounds  the  hip  joint  on  all 
sides  ;  the  symptoms  ai-e  then  often  identical,  and  only  the  discovery  of 
the  spinal  or  iliac  disease  can  clear  up  the  case.  In  other  instances  free 
mobility  of  the  joint  through  a  certain  range  in  all  directions  excludes  hip 
disease.  Rectal  examination  enables  us  to  distinguish  between  hip  disease 
and  spinal  gluteal  abscess,  since  in  the  latter  the  abscess  can  be  felt  to 
extend  upwards  over  the  brim  of  the  pelvis. 

Abscess  connected  with  the  Ccccum,  or  sigmoid  flexure,  is  not  uncommonly 
mistaken  for  hip  disease.     Such  cases  closely  resemble  iliac  abscesses  from 


Diagnosis  699 

other  causes,  with  the  addition  of  symptoms  indicating  connection  with  or 
proximity  to  the  large  bowel.' 

Congenital  atrophy  of  the  femur  is  not  likely  to  be  mistaken  for  recent 
disease,  but  may,  perhaps,  be  a  result  of  intra-uterine  affection  of  the 
joint. 

One  of  the  commoner  sources  of  error  is  enlargement  of  the  iliac  or  of 
the  inguinal  glands  ;  pain,  lameness,  fle.xion,  and  some  rigidity  of  the  joint 
are  found  ;  on  examination  by  deep  pressure  above  Poupart's  ligament  the 
enlarged  glands  may  be  felt,  and  palpation  is  painful ;  careful  search,  how- 
ever, will  show  rigidity  only  in  extension  or  slightly  in  abduction  as  well, 
while  flexion,  abduction,  and  rotation  are  free  ;  there  is  no  trochantei'ic 
thickening  and  no  evidence  of  effusion  into  the  joint.  It  must  be  remembered 
that  the  glandular  enlargement  may  be  due  to  hip  disease  itself. 

It  is  always  well  to  use  the  '  method  of  exclusion '  in  doubtful  cases,  and 
to  bear  in  mind  that  there  is  no  one  symptom  pathognomonic  of  hip  disease, 
but  that,  as  in  other  morbid  conditions,  several  factors  have  to  be  taken  into 
account  in  forming  a  diagnosis.  Free^  stnooth,  painless  viobility  is  perhaps 
tJie  most  satisfactory  evidence  of  the  absence  of  Jiip  disease. 

To  sum  up  the  diagnostic  points  of  hip  disease.  A  patient  who  is  a  child, 
who  walks  lame,  especially  after  a  little  exercise,  who  has  thickening  of  the 
trochanter,  some  tenderness  on  pressure  over  the  hip  joint,  and  pain  together 
with  slight  flexion  and  some  immobility  of  the  joint,  without  evidence  of 
spinal  or  sacro-iliac  disease  or  pain  in  anj'  part  higher  than  the  hip,  and  in 
whom  pain  is  increased  by  abduction  or  rotation  inwards,  has  got  disease  of 
the  hip.  We  would  here  lay  stress  upon  the  fact  that  there  is  not  the  smallest 
necessity  for  hurting  a  child  in  an  examination  for  hip  disease.  It  is  true 
that  pressure  upon  the  trochanter  or  heel,  what  is  expressively  called  by 
American  surgeons  '  crowding  the  joint  surfaces  together,'  gives  rise  to  pain 
in  disease  of  the  joint,  but  it  is  neither  a  necessary  nor  a  pathognomonic 
sign.  Night  starting  is  a  valuable,  but  not  a  constant  nor  always  trustworthy, 
symptom.  Later  in  the  disease  the  problem  is  usually  easily  solved,  but 
not  always,  for,  as  indicated  above,  disease  of  the  trochanter  or  abscess 
around  the  joint,  as  well  as  bursitis,  may  resemble  hip  disease  very  closely; 
in  such  cases  the  position  and  swelling  of  hip  disease,  as  well  as  its  rigidity, 
are  very  closely  simulated,  and  we  must  rely  on  other  points.  Such  condi- 
tions can,  however,  only  be  mistaken  for  the  later  stages  of  the  disease,  in 
which  there  will  be  shortening  of  the  limb,  raising  of  the  trochanter,  and 
probably  grating  in  the  joint  if  examination  is  made  under  chloroform.  It 
is  only  occasionally  that  we  see  a  child  in  quite  the  first  stage  before  the 
mischief  has  reached  the  surface  of  the  bone  ;  in  such  case  pain,  lame- 
ness, slight  flexion,  and  slight  rigidity  are  the  principal  signs.  Usually  the 
patient  is  brought  in  the  early  second  stage,  when  trochanteric  blurring  is 
found. 

Believing,  as  we  do,  that  chronic  hip  disease  in  children  begins  invariably, 
or  nearly  so,  as  an  osteomyelitis,  we  cannot  follow  BarwelFs  distinctions  in 
the  diagnosis  of  this  condition  from  synovitis  ;  but  see  p.  690.  We  do, 
however,   think   that   acute  synovitis  can  be   distinguished   from  the  early 

1  Vide  paper  '  On  Some  Forms  of  Abdominal  Abscess  occurring  in  Children,'  by 
G.  A.  \\'right,  in  Arch,  of  Pcediatrics.  1884;  also  Lancet,  1890. 


/OO  Hip  Disease 

stages  of  true  hip  disease  by  the  greater  pain  on  movement  of  the  joint,  with 
absence  of  trochanteric  thickening,  and  under  chloroform  free  and  perfect 
mobihty  ;  there  may  be  also  swelling  in  front  of  the  joint,  but  this  depends 
upon  rhe  amount  of  the  effusion.  In  simple  traumatic  synovitis  the  mischief 
immediately  follows  the  injury,  while  in  the  bone  lesion  there  is  usually  an 
interval  of  two  or  three  weeks,  or  often  months,  between  the  accident  and 
the  onset  of  symptoms  ;  thus  the  child  falls,  cries  for  a  few  minutes,  but  is 
then  well  again,  and  in  a  month's  time  begins  to  limp.  This  evidence  of  the 
history  is  most  important.  Careful  inquiry  should  always  be  made  in  every 
case  for  any  previous  trouble  about  the  hip,  since  the  acute  symptoms  may 
be  grafted  upon  old  latent  disease. 

Acute  osteomyehtis  is  readily  diagnosed  ;  great  constitutional  disturbance, 
fever  and  prostration,  great  pain,  amounting  to  agony  on  the  least  movement, 
helplessness  of  the  limb,  rapid  and  extensive  swelling,  with  venous  turgidity, 
make  the  diagnosis  easy. 

Mr.  Howard  Marsh,  in  his  valuable  paper  in  the  '  British  Medical  Journal ' 
for  1877,  gives  us  most  useful  information  on  the  diagnosis  of  hip  disease. 
Thus,  he  points  out  that,  though  flexion  may  be  free  in  some  cases,  the 
flexed  limb  is  carried  into  abduction,  and  not  straight  up  towards  the 
abdomen  ;  again,  flexion  may  be  limited  in  cases  of  gluteal,  or  extension  in 
cases  of  psoas  abscess,  but  in  hip  disease  both  are  limited  in  their  more  ex- 
treme degrees,  even  if  free  in  part  of  the  range  of  mobility.  His  caution  as 
to  the  dangers  of  frightening  the  muscles  into  spasm  is  also  well  worth 
remembering.  In  examining  children  it  is  always  wise  to  manipulate  the 
sound  limb  first,  as  this  gives  the  child  confidence  that  he  is  not  going  to  be 
hurt,  and  he  is  less  likely  to  voluntarily  hold  the  joint  stiff.  Rectal  examina- 
tion for  thickening  of  the  inner  wall  of  the  acetabulum  we  have  occasionally 
found  of  value  in  doubtful  cases,  and  it  certainly  should  be  employed  if  there 
is  any  suspicion  of  primary  acetabular  disease  ;  under  such  circumstances  it 
may  be  the  only  way  to  clear  up  the  doubt.  An  excellent  account  of  it  is 
given  in  Dhourdin's  work,  '  De  la  Coxalgie  Cotyloidienne.' 

In  examining  a  child  for  suspected  hip  disease  in  an  early  stage  the 
course  of  procedure  should  be  as  follows.  First,  the  child's  confidence  should 
be  gained,  so  that  it  will  not  be  afraid  ;  next,  all  clothing  should  be  removed 
and  a  blanket  wrapped  round  the  patient,  who  should  be  allowed  to  walk  to 
a  flat,  hard  couch  or  table  covered  with  a  rug.  The  position  of  the  limb  and 
the  child's  gait  should  be  carefully  watched.  Then,  with  the  child  lying 
straight  and  flat  upon  its  back,  any  abduction  of  the  limb  should  be  looked 
for,  an  imaginary  test  line  passing  downwards  from  the  middle  of  the 
sternum  through  the  umbilicus  and  pubes  being  taken  as  the  guide.  The 
length  of  the  two  limbs,  taking  into  account  the  pelvic  tilting,  is  now  to  be 
compared.  The  next  point  is  to  notice  whether  the  affected  limb  is  put 
down  flat  upon  the  table — i.e.  whether  the  thigh  and  knee  are  flexed  or  the 
back  arched  (lordosis) — also  whether  there  is  any  wasting  of  the  limb. 
The  surgeon  should  then  take  the  sound  limb  gently  in  the  hand  and  fully 
flex  it,  looking  for  any  movement  of  the  pelvis  ;  as  soon  as  the  full  degree  of 
flexion  has  been  ascertained  the  affected  limb  should  be  very  gently  raised 
and  its  range  of  mobihty  compared  with  that  of  the  sound  side,  a  finger 
being  kept  on  the  anterior  superior  spine  of  the  ilium  to  feel  for  any  tilting 


Prognosis  yo  i 

of  the  pelvis.  Should  there  be  any  lordosis  due  to  fixed  flexion  of  the  hip, 
this  will  disappear  as  the  limb  is  raised  and  be  increased  by  extending  the 
leg.  The  finger,  or  better  the  thumb,  should  then  be  gently  pressed  into 
each  iliac  fossa  to  feel  for  swelling  there,  due  to  enlarged  glands  or  the 
presence  of  an  abscess  ;  fulness  below  Poupart's  ligament  should  also  be 
looked  for.  If  no  restriction  of  movement  has  been  found,  abduction, 
adduction,  and  rotation  should  be  tested  and  the  two  sides  compared. 

The  child  should  next  turn  over  and  lie  on  its  face — it  is  generally  better 
to  allow  it  to  turn  in  its  own  way  ;  the  shape  of  the  buttock,  the  thickness 
of  the  trochanters,  the  gluteal  fold,  and  rima  natium  are  now  inspected  and 
the  range  of  extension  further  investigated.  The  spine  and  sacro-iliac  joints 
should  be  examined  at  this  stage,  swelling  of  the  knee  joint  and  thickening 
of  the  shaft  of  the  femur  having  been  previously  searched  for.  If  there  is 
still  a  doubt,  a  finger  should  be  passed  into  the  rectum,  and  the  inner  wall 
of  the  pelvis  examined  for  thickening,  or  abscess,  or  enlarged  glands  ;  for 
this  proceeding  it  is  often  necessary  to  give  an  anaesthetic.  Where  disease 
begins  in  the  acetabulum,  but  has  not  yet  reached  the  cavity  of  the  joint,  pain 
and  slight  lameness  may  be  the  only  obvious  symptoms.  Mobility  of  the 
joint  may  be  almost  perfect.  In  such  cases  the  presence  of  thickening  felt 
per  rectum  as  well  as  by  deep  pressure  in  the  iliac  fossa  is  all-important  as  a 
means  of  diagnosis. 

No  one  symptom  alone  is  sufficient  for  a  diagnosis  in  early  stages,  but 
limitation  of  movement  to  some  extent,  and  trochanteric  thickening,  are 
perhaps  the  two  most  valuable  signs  of  joint  disease. 

We  would  here  deprecate  the  use  of  any  of  the  means  of  diagnosis  which 
necessitate  giving  pain  to  the  patient.  The  presence  of  disease  is  re- 
cognisable by  the  painless  mode  of  examination  in  all  cases  where  it  can  be 
made  out  at  all.  In  all  cases  examination  for  hip  disease  should  be  made 
with  the  child  completely  stripped,  and  lying  on  a  /lai  hard  couch  or 
table. 

Prog/iosis.^A.s  regards  the  prognosis  and  the  results  of  afifections  of  the 
hip  joint  when  treated  by  means  other  than  operation,  it  is  necessary  to  dis- 
tinguish clearly  between  the  two  morbid  conditions  of  acute  synovitis  and 
osteomyelitis,  acute  or  chronic  :  the  former  recover  perfectly  with  freely 
movable  joints  under  proper  treatment,  and  show  no  after  ill  effects,  though 
the  treatment  required  is  usually  longer  than  that  for  other  joints.  On  the 
other  hand,  cases  of  true  hip  disease,  unless  effectually  treated  in  the  early 
stage^  very  rarely  recover  without  more  or  less  destruction  of  the  upper 
epiphysis  of  the  femur,  usually  accompanied  by  abscess,  and  always  result  in 
shortening  with  more  or  less  deformity,  and  a  very  large  majority  die  before 
reaching  adult  life. 

Even  when  tuberculous  disease  of  the  hip  seems  to  have  subsided, 
relapses  are  exceedingly  common  after  some  slight  injury  or  intercurrent 
illness.  It  is  important,  however,  to  distinguish  between  relapses  due  to  a 
fresh  lighting  up  of  disease  and  the  presence  of  an  abscess  the  result  of  irri- 
tation by  some  quiescent  local  product  of  former  inflammation — the  residual 
abscess  of  Paget. 

As  to  the  usefulness  of  the  limb  after  recovery  from  hijj  disease  without 
operation,  more  or  less  shortening  is  to  be  expected  in  all  cases,  either  as  a 


yo2 


Hip  Disease 


result  of  malposition,  retraction  of  the  femur  upon  the  dorsum  ilii,  actual 
destruction  of  bone,  or  arrest  of  growth  of  the  femur  ;  the  last  is  the  least 
important  factor,  since  increase  of  length  in  the  femur  takes  place  almost 
entirely  at  the  lower  end,  and  what  shortening  there  is  is  due  rather  to 
general  arrest  of  growth  of  the  limb  than  to  destruction  of  the  upper  growing 
line. 

In  private  practice,  where  hip  disease  is  seen  early  and  treated  more 
effectually  than  it  can  be  in  hospital  practice,  the  prospect  of  recovery  is 
much  better,  though  even  here  a  perfect  result  is  rare  ;  it  will,  however,  be 
obtained  under  exceptionally  favourable  conditions.  A  movable  joint  may 
be  obtained  where  the  disease  comes  under  treatment  in  its  early  stage,  or 
even  after  destruction  of  the  joint  there  may  be  a  certain  amount  of  mobility, 
though  this  is  less  frequent  than  it  is  after  excision. 

In  fatal  cases  of  hip  disease  death  is  generally  due  to  tuberculosis  or 
exhaustion,  with  hectic  or  lardaceous  disease  ;  sometimes  an  intercurrent 
exanthem  proves  fatal.  Hence  it  is  seen  the  prognosis  depends  very 
largely  upon  whether  early  and  efficient  treatment,  of  which  that  by 
Thomas's  splint  is  undoubtedly  the  best,  can  be  obtained.  The  cases  least 
likely  to  do  well  without  operation  are  those  in  which  there  is  a  great  amount 
of  thickening,  and  those  in  which,  in  spite  of  fixation,  pain  continues,  while 


Fig.  i6i. — Br^rant's  Splint.     We  have  had  sliding  pieces  made  to  fill  up  the  interruptions 
when  required  ;  this  is  seen  in  the  figure. 


under  any  circumstances  the  prognosis  is  bad  if  there  is  extensive  pelvic 
caries  (not  necrosis). 

Treatment. — First,  the  ideal  treatment  consists  in  seeing  the  case  early, 
keeping  the  child  in  bed  until  by  simple  extension  or  a  Br^^ant's  splint  the 
limb  is  straightened ;  then  a  Thomas's  splint  should  be  applied,^  and  the 
child  allowed  to  get  up  and  about,  out  of  doors,  by  the  seaside.  Good 
food,  cod-liver  oil  and  iron,  with  occasional  administrations  of  rhubarb  and 
soda  if  any  dyspeptic  troubles  appear,  comprise  the  rest  of  the  management. 
Two  years  should  be  the  time  given  for  rigid  treatment  ;  after  this  the 
splint  may  be  gradually  laid  aside,  and  the  child  allowed  to  go  about  with 
a  patten  and  crutches  for  a  few  weeks  ;  if  there  is  still  no  sign  of  disease, 
walking  upon  the  affected  limb  may  be  gradually  permitted.  During  the 
time  of  treatment  the  greatest  care  must  be  taken  not  to  allow  the  foot  of 
the  affected  side  to  touch  the  ground,  and  to  avoid  all  falls  or  strains  of  the 
joint. 

American  surgeons  use  to  a  great  extent  '  traction  splints '  of  various 
forms,  in  which,  while  the  patient  gets  about  moi-e  or  less,  extension  is  kept 

1  Or  tlie  limb  may  be  straightened  by  means  of  the  Thomas's  splint. 


Treatment  by  Extension 


703 


up.^  The  weak  point  in  most  of  these  appHances  is  that  the  joint  is  not 
fixed,  though  fixtion  of  the  joint  is  now  much  more  generally  recognised 
as  essential  than  it  was  some  years  ago. 

In  hospital  practice  the  nearest  approach  to  the  above  lines  of  treatment 
should  of  course  be  carried  out,  but  if  there  is  progressive  disease,  and  the 
management  is  unsatisfactory,  the  Cjuestion  of  operation  must  be  considered. 
If  sinuses  e.\ist  with  receding  disease,  diminishing  discharge,  and  puckering  in 
of  cicatrices,  or  if  with  an  abscess  the  mischiet  is  quite  cjuiescent  or  receding, 
non-operative  treatment  should  be  adopted  for  a  time,  if  it  can  be  thoroughly 
carried  out  ;  if  not,  or  if  no  progress  is  made  in  a  few  weeks,  the  diseased 
part  should  be  removed. 

In  applying  extension  by  weight  it  should  be  made  an  invariable  rule  to 
make  traction  from  the  condyles  of  the  femur,  and  not  from  below  the 
knee.  A  case  is  on  record  in  which  prolonged  extension  applied  below  the 
knee  resulted  in  separation  of  the  upper  epiphysis  of  the  tibia.      It  is  also 


Fig.  162. — Shows  extension  by  a  weight  applied  above  the  knee,  with  a  long  splint  on  the 
sound  side.  Also  the  simple  plan  of  keeping  the  child  from  sitting  up  by  means  of  the  board 
running  behind  the  shoulders  and  fastened  to  the  side  of  the  bed.  The  shoulders  are 
fastened  to  this  board,  and  the  arms  are  left  free  below  the  elbow.  The  bed  on  which  the 
child  lies  is  somewhat  too  soft. 

objectionable  in  that  it  throws  strain  upon  the  knee  joint,  and  is  more  apt  to 
slip  off.  The  strapping  should  always,  if  possible,  be  applied  for  some  hours 
before  the  weight  is  attached,  in  order  that  the  plaster  may  get  set,  and  not 
be  dragged  off  by  the  weight.  The  strapping  (of  which  Leslie's  brown 
hoUand  is  the  best)  should  be  kept  from  the  skin  by  a  strip  of  lint  or  flannel 
bandage,  or  part  of  a  stocking,  to  protect  the  sharp  edge  of  the  tibia  and  the 
prominences  of  the  joint  from  pressure  (fig.  162). 

We  have  found  that  too  great  extension  may  be  a  cause  of  painful 
spasms,  and  it  is  well  to  bear  this  in  mind,  that  too  great  extending  force  and 
too  little  are  alike  inefficient.  In  cases  where  treatment  without  operation 
is  carried  out,  as  for  instance  where  adhesions,  the  result  of  old  inflam- 
mation, exist,  or  nmscular  contracture  has  taken  place,  the  deformity  may 
be  remedied  in  many  instances  by  the  ordinary  extension  apparatus,  by  a 

1  For  a  good  account  of  these  splints  we  must  refer  to  Dr.  Lovett's  work  on  Disease  of 
the  Hip,  1892. 


704  Hip  Disease 

weight,  or  by  Bryant's  splint.  In  other  cases,  where  simple  extension  is 
inefficient,  or  too  tedious,  it  may  be  necessary  to  forcibly  straighten  the 
limb  under  chloroform,  and  then  fix  it  by  splints  in  its  new  position.  The 
advisability  of  forcible  straightening  is  a  somewhat  disputed  point  and  is 
not  in  all  cases  free  from  risk,  not  only  of  laceration  of  important  structures, 
but  of  setting  up  fresh  inflammation  in  the  joint  or  what  remains  of  it. 

Mr.  Howard  Marsh,^  and  in  1836  Sir  Benjamin  Brodie,  advised  that 
the  extension  should  be  made  in  the  axis  of  the  misplaced  limb,  and  that 
the  direction  should  be  altered  as  the  limb  regains  its  normal  position.  We 
do  not  think  this  a  matter  of  great  importance.  If  it  is  desii-ed  to  carry  out 
this  plan,  probably  Hodgen's  splint  for  fracture  of  the  thigh  would  be  the 
most  efficient  apparatus. 

It  is  sometimes  a  matter  of  difficulty  to  remedy  the  malposition  of  the 
limb  in  cases  of  fixation  in  combined  flexion  and  adduction  or  abduction. 
Here,  where  possible,  gradual  reduction  by  a  Bryant's  splint  is  the  best 
treatment  (fig.  161)  ;  failing  this — and  it'cannot  be  always  used — along  splint 
on  one  side,  with  a  weight  to  the  mal-placed  side,  should  be  tried  (fig.  162)  ; 
and,  failing  this,  careful  straightening  under  chloroform.  Where  there  is 
much  abduction  Volkmann  applies  a  weight  to  each  leg,  the  heavier  one 
being  attached  to  the  sound  side.  (A.  H.  Tubby.)  These  methods  are,  we 
thmk,  better  than  remedying  the  deformity  by  weights  applied  laterally.  In 
more  acute  cases,  where  the  deformity  is  mainly  due  to  spasm,  gradual 
extension  is  best,  but  by  some  means  the  limb  must  be  got  as  quickly  as 
possible  into  good  position. 

Thomas's  apparatus  is  a  very  valuable  appliance,  and  is  undoubtedly  the 
best  splint  we  have  for  patients  able  to  be  up  (figs.  163  and  164).  The  spHnt 
requires  careful  attention  to  detail,  both  in  fitting  it  and  in  management  ;  it 
is  of  use,  first,  in  the  early  stages  of  disease,  where  it  is  possible  to  give  the 
child  the  chance  of  long-continued  and  perfect  rest,  with  general  hygienic 
measures  ;  and,  secondly,  after  excision,  to  keep  the  limb  quiet  for  a  time 
until  the  parts  are  sufficiently  consolidated  to  allow  of  movement  being 
begun.     We  have  habitually  used  it  for  many  years. 

The  question  of  when  to  excise  a  hip  joint  is  no  doubt  a  difficult  one,  but 
the  conclusion  we  have  come  to  is  this.  Treatment,  short  of  excision,  when 
once  suppuration  occurs,  is,  if  the  disease  is  prog7'-essing^  useful  only  as  a 
palliative.  Our  opinion,  bearing  in  mind  Mr.  Holmes's  valuable  remarks 
on  the  social  ciixumstances  of  these  patients,  is  that  where  there  is  an 
abscess  outside  the  joint,  or,  without  this,  great  trochanteric  thickening,  with 
much  pain  that  does  not  yield  to  treatment  by  rest  and  efficient  cleaning  out 
of  the  '  abscess,'  excision  ought  to  be  performed.  In  private  practice  cases 
are  usually  seen  in  the  first  or  early  second  stage,  and  it  is  possible  to 
ensure  that  the  Thomas's  splint  shall  be  kept  on  and  no  strain  thrown  upon 
the  joint  :  hence  recoveiy  without  operation  is  the  rule.  While  fully  aware 
that  abscesses  disappear  and  tuberculous  lesions  cicatrise  under  favourable 
circumstances,  we  think  that  in  the  case  of  the  hip  delay  is  unwise  among 
the  hospital  class,  with  whom  it  is  as  yet  impossible  to  deal  on  the  same 
lines  as  with  the  well-to-do.  In  almost  every  instance  we  have  found  much 
more  extensive  disease  than  might  be  expected  from  the  external  evidence, 
1  Brit.  Med.  Jour.  July  1876. 


Excision  of  the  Hip  705 

unless  the  pathology  of  the  affection  is  borne  in  mind,  and  we  beHcvc  that, 
once  this  chronic  osteomyeHtis  is  fully  established,  excision  in  a  large  pro- 
portion of  hospital  casds  is  the  proper  course.  Nature,  of  course,  in  many 
cases  will,  unaided,  get  rid  of  the  dead  bone  by  slow  and  tedious  processes, 
but  the  number  of  children  who  can  survive  the  process  of  elimination  is 
very  small,  while  the  mortality  after  early  excision  is  not  great,  and  the 
failures  are  mainly  in  those  instances  where  the  operation  has  been  put  off 
till  too  late.  Where  actual  necrosis,  or  caries  of  the  head  of  the  femur,  with 
destruction  of  bone  and  cartilage,  and  often  sequestra  of  varying  size  in  the 
acetabulum,  or  at  least  caries  of  it,  is  known  to  exist,  we  think  few  advocates 
of  non-operative  treatment  will  be  found.     It  is  then,  as  Mr.  Bryant  points 


Fig.  164.  —Thomas's  Hip  Splint  adjusted 
for  a  case  with  no  deformity. 


Fig.  163. — Thomas  s  Hip  Splint,  applied.  Slightly 
altered  from  Mr.  Thomas's  work  on  the  '"Hip, 
Knee,  and  Ankle.' 

out,  to  be  looked  upon  rather  as  an  ordinary  operation  for  necrosed  bone 
than  anything  more  formidable  ;  and  that  this  is  the  state  of  the  joint  even 
in  cases  often  spoken  of  as  those  of  early  disease  is  the  fact  upon  which  we 
should  like  to  lay  stress. 

While  we  advise  excision  in  all  cases  in  which  the  ^\'s.&-as& progresses  in  spite 
of  adequate  treatment,  we  have  come  to  the  belief  that  modern  methods  of 
abscess  treatment  and  efficient  use  of  splints  have  enabled  us  to  reduce  the 
number  of  excisions.  Thus  in  seven  years,  1886-93,  83  excisions  were  per- 
formed, while  in  five  years,  1894- 1898,  31  excisions  of  the  hip  were  done 
at  the  Children's  Hospital  by  the  writer. 

It    is    necessary   of  course  to  distinguish  sharply  between  abscess  the 

z  z 


7o6  Hip  Disease 

result  of  progressive  disease  and  residual  abscess  ;  it  is  in  the  former  that 
the  question  of  excision  arises.  Where  the  disease  is  quiescent,  abscesses 
may  well  be  dealt  with  by  the  method  already  described,  of  thorough 
cleaning  out  and  closure  after  injection  of  iodoform  emulsion.  We  are  not 
disposed  to  think  that  mere  injection  of  iodoform  into  tuberculous  joints  with- 
out removal  of  the  original  focus  of  disease  will  be  successful  to  any  great 
extent.  It  is  undoubtedly  useful  in  some  cases  to  deal  with  the  abscess 
first,  and,  when  that  has  healed,  to  remove  the  diseased  bone  by  a  second 
operation  under  more  favourable  conditions.  The  operation  of  excision  is 
discredited  because  it  is  put  off  until  disease  is  so  far  advanced  that  no  mode 
of  treatment  can  have  more  than  a  small  proportion  of  good  results  ;  while 
timely  excision  cuts  short  the  disease,  saves  pain,  lessens  the  time  of  treat- 
ment, and  gives  a  better  limb. 

We  have  in  this  edition  considerably  modified  our  statements  in  former 
editions  as  to  excision.  We  do  not  perform  excision  now  as  frequently  as  we 
did  in  former  years.  Cases  of  hip  disease  are  brought,  we  think,  earlier  than 
they  formerly  were,  the  treatment  of  them  has  been  more  efficient  before 
they  are  brought  to  hospital,  and  the  treatment  in  hospital  is  also  better. 
Probably  a  not  less  important  factor  in  the  reduction  of  excision  operations 
is  the  great  advance  in  the  treatment  of  '  abscess.'  The  modern  method  of 
thoroughly  cleaning  out  the  cavity  with  removal  of  all  detritus  and  closing 
it  again  completely  by  suture  reduces  a  certain  number  of  these  cases  to  a 
condition  nearly  corresponding  to  early  disease.  Hence  we  have  reduced, 
and  hope  still  further  to  reduce,  the  number  of  cases  of  disease  in  all  joints 
which  require  radical  operations.  While  thus  recording  with  satisfaction 
our  belief  in  the  important  advance  made  of  late  years  in  the  treatment  of 
joint  disease,  we  still  urge  the  importance  of  excision  in  every  case  in  which 
in  spite  of  good  treatment  the  disease  is  progressive,  and  not  only  this,  but 
excision  before  the  disease  has  gone  too  far.  If  we  leave  it  as  a  last  resort 
we  shall  diminish  the  number  of  excisions,  but  increase  the  roll  of  amputa- 
tions and  deaths.  Excision  must  of  course  always  be  necessary  where  pelvic 
or  extensive  femoral  necrosis  exists. 

Modes  of  Excision. — Various  incisions  for  removal  of  the  upper  end  of 
the  femur  have  been  advocated.  Of  these  the  incision  over  the  middle  of 
the  trochanter  and  slightly  concave  forward  is  the  one  we  usually  adopt. 
We  see  no  advantage  in  most  of  the  others  over  the  one  extending  downwards 
for  about  three  inches,  more  or  less  according  to  age  and  the  extent  of  the 
disease,  along  the  middle  of  the  trochanter.  Whei-e,  however,  it  is  proposed 
to  remove  a  large  part  of  the  pelvic  wall,  a  flap  operation  is  desirable,  and 
we  have  recently  frequently  used  it  ;  the  flap  incision  has  the  advantage  of 
freely  exposing  the  diseased  area  and  allowing  thorough  cleaning  of  the  soft 
parts,  and  by  chiselling  off  and  turning  up  the  trochanter  with  its  muscles 
attached  the  power  to  move  the  limb  subsequently  is  likely  to  be  greater. 

Next,  if  a  flap  is  not  made,  the  soft  parts  should  be  divided  vertically 
above  the  trochanter  and  the  capsule  opened  freely,  if  this  has  not  been 
done  by  the  first  incision.  The  joint  should  then  be  explored  with  the 
finger. 

The  next  step  is  to  separate  the  soft  tissues  from  the  bone  on  the  inner 
side,  stripping  back  the  periosteum  as  far  as  it  exists  as  such.     The  finger 


I 


Excision  of  the  Hip  707 

should  then  be  used  to  pass  round  the  bone  and  feel  that  the  upper  end 
is  free  ;  next,  still  using  the  finger  as  a  guard  at  the  inner  side  of  the  bone, 
the  femur  should  be  sawn  through  just  below  the  trochanteric  margin  with  a 
keyhole-  or  finger-saw.  Some  pai't  of  the  trochanteric  epiphysis  is  usually 
left  behind.  The  upper  extremity  of  the  bone  is  then  readily  prised  out  with 
the  finger  or  raspatory.  The  acetabulum  should  be  then  examined  and  any 
sequestra  removed.  If  there  is  a  large  carious  surface,  it  may  be  gouged  or 
scraped  with  a  Volkmann's  spoon  or  left  alone.  It  is  well  to  remove  any 
rough  or  semi-necrosed  bone,  but  we  doubt  the  possibilitv  of  being  able  to 
remove  all  the  disease  without  greatly  adding  to  the  severity  of  the  operation 
where  there  is  extensive  inflammation  without  necrosis,  nor  is  such  treatment 
desirable. 

The  upper  end  of  the  femur  should  be  examined  to  see  if  the  whole 
disease  has  been  removed  ;  if  not,  a  further  section  should  be  made,  and 
this  may  be  carried  a  considerable  distance  down  the  shaft  ;  six  inches  have 
been  removed  with  a  good  result,  and  but  little  shortening,  by  an  American 
surgeon. 

Here  it  is  well  to  point  out  the  danger  of  the  practice  of  thrusting  the 
head  of  the  femur  forcibly  out  of  the  wound  before  sawing  it  through,  instead 
of  dividing  it  i7t  situ.  Several  cases  of  fracture  of  the  shaft  of  the  atrophied 
fatty  bone  have  occurred.  An  additional  objection  to  this  practice  is  the 
ease  with  which  the  periosteum  may  be  thus  stripped  off  the  inner  aspect  of 
the  shaft,  and  so  necrosis  may  occur. 

The  operation  is  much  more  easily  and  safely  done  in  the  way  described, 
and  involves  less  violence  to  and  less  division  of  the  soft  parts.  The  finger 
is  quite  as  good  a  guide  as  the  eye  to  the  condition  of  the  bone. 

Usually  no  vessels  require  ligatures,  though  there  is  sometimes  free 
oozing  of  blood.  If  the  wound  can  be  made  aseptic,  it  should  be  carefully 
cleaned  and  closed  by  suture's  after  injection  of  iodoform  emulsion  ;  if  the 
case  is  one  with  old-standing  sinuses,  we  prefer  to  leave  it  quite  open,  and  in 
that  case  a  large  drainage  tube  should  be  passed  deep  into  the  cavity  of  the 
joint.  Any  sinuses  or  abscess  cavities  should  then  be  thoroughly  scraped 
out  and  well  cleaned  before  applying  the  dressing'.  It  will  often  be  found 
that  a  distinct  membranous  layer  of  lymph  lines  the  cavity  of  the  articulation, 
but  there  is  rarely  anything  like  the  thickness  of  granulation  tissue  so  often 
seen  in  the  knee  and  other  joints.  It  is  well  to  remove  any  masses  of  pulpy 
granulations  should  they  exist,  but  anything  like  the  elaborate  dissection 
required  in  erasion  of  the  knee  is  impracticable. 

In  many  cases  we  make  our  section  through  the  neck  of  the  femur,  but 
in  some  cases  the  head  of  the  femur  is  so  far  destroyed  that  it  would  be 
impossible  to  do  less  than  take  away  the  trochanter,  while  the  trochanter  if 
left  in  cases  that  require  drainage  tends  to  block  up  the  orifice  of  the  wound 
and  prevents  the  free  escape  of  discharge  and  debris  of  bone,  and  thus 
interferes  with  one  of  the  main  objects  of  the  operation.  This  argument 
does  not,  of  course,  apply  where  it  is  possible  to  close  the  wound  entirely. 
The  Clinical  Society's  Committee  advised  that  the  ti'ochanter  should  be  left 
unless  diseased,  or  unless  there  is  extensive  pelvic  disease,  and  where  the 
flap  operation  is  employed  it  must  be  left. 

Where  intrapelvic  abscess  exists  the  acetabulum  should  be  perforated. 

z  z  2 


70  8  Hip  Disease 

Examination  per  rectum  enables  the  diagnosis  to  be  made  if  this  condition 
is  suspected. 

The  most  convenient  form  of  dressing  afterwards  is  a  thick  pad  of  wood- 
wool wadding,  over  a  thin  layer  of  wet  gauze.  Iodoform  should  be  freely 
dusted  into  the  wound  before  applying  the  dressings,  or  iodoform  emulsion 
injected. 

Messrs.  Barker  and  Pollard,  in  December  1888,  brought  before  the  Medical 
and  Chirurgical  Society  of  London  a  method  of  managing  the  operation  of 
excision  of  the  hip.  The  method  consists  in  clearing  away  all  disease  of  the 
soft  parts  by  scraping  or  excision  ;  scraping"  out  abscess  cavities,  and  by 
means  of  thorough  and  careful  asepticism  getting  the  wound  clean.  The 
novelty  is  in  their  mode  of  carefully  drying  out  the  wound  and  closing  it  en- 
tirely after  removal  of  all  tuberculous  material  as  far  as  possible,  so  that 
primary  union  is  obtained.  Messrs.  Barker  and  Pollard  showed  cases  in 
which  this  result  had  been  obtained,  and  we  have  since  then  followed  their 
plan  in  its  main  features  with  success.  There  is  no  doubt  this  is  a  most 
valuable  improvement  ;  it  is,  of  course,  applicable  to  cases  of  early  excision 
chiefly,  or  only,  and  experience  shows  that  even  so  there  is  some  danger  of 
relapse  (p.  711).  For  further  details  we  must  refer  to  the  '  Medico-Chir. 
Transactions,'  1888  ;  but  we  may  reprint  here  Mi\  Pollard's  abstract  of  the 
essentials  of  the  method  : 

1.  The  whole  of  the  tubercular  growth  must  be  removed. 

2.  Perfect  asepsis  must  be  assured. 

3.  Bleeding  must  be  checked  and  the  wound  made  as  dry  as  possible. 

4.  Oozing  must  be  checked  by  the  even,  elastic  support  of  a  wool  dressing 
and  a  moderately  tight  bandage. 

5.  Absolute  rest  of  the  part  must  be  maintained  during  the  process  of 
healing. 

Following  Mr.  Howse,  we  prefer  to  have  the  extension  put  on  before  the 
operation,  so  that  the  weights,  or,  better,  Bryant's  splint,  can  be  applied  at 
once  before  the  patient  is  put  to  bed.  The  shock  of  the  operation  is  some- 
times somewhat  sevei-e,  but  usually  soon  passes  off  under  the  use  of  opium 
and  stimulants.  Rarely,  however,  much  more  severe  and  prolonged  shock 
occurs. 

The  subsequent  management  of  the  case  requires  some  special  remarks. 
It  is  exceedingly  difficult  to  keep  the  wound  aseptic  in  cases  where  sinuses 
have  previously  existed  or  where  there  is  widespread  suppuration.  It  is, 
however,  a  great  gain  if  the  wounds  can  be  kept  sweet  even  for  a  time,  and 
with  present  methods  primary  union  after  excision  may  be  expected  in  a  large 
proportion  of  cases.      Vide  Note,  p,  712. 

The  after-treatment  of  cases  of  excision  simply  consists  in  dressing  and 
in  keeping  the  limb  quiet  and  in  good  position.  This  maybe  done  by  vai'ious 
means,  of  which  the  best  are  simple  extension  by  a  weight  (the  weight  may 
usually  be  reckoned  at  one  pound  for  each  year  of  the  child's  age  from  two  to 
six  ;  six  pounds  is  generally  enough  up  to  twelve  years  of  age,  after  which 
more  may  be  added),  with  or  without  a  long  splint  on  the  opposite  side,  and 
a,  Bryant's  double  splint,  which  has  many  advantages  in  securing  '  parallelism 
of  the  two  limbs,'  and  in  the  ease  and  comfort  with  which  the  patient  can  be 
moved.  It  is  an  invaluable  apparatus,  and  we  now  almost  invariably 
use  it. 


Excision  of  the  Hip  yog 

The  sooner  excision  cases  are  got  up  and  about  the  better  ;  some  cases 
may  leave  their  beds  in  three  weeks  ;  others,  of  course,  are  much  longer  in 
getting  up,  the  difference  depending  mainly  upon  the  state  of  the  disease  at 
the  time  of  operation. 

The  period  of  convalescence  after  excision  varies  from  the  time  mentioned 
to  two  years,  while  in  some  cases  sinuses  may  remain  open  much  longer  if 
pelvic  disease  exists.  We  keep  our  patients  usually  in  a  Thomas's  splint  for 
from  at  least  three  to  six  months  after  excision  ;  after  this  the  child,  if 
old  enough,  should  get  about  with  a  patten  and  crutches,  allowing  the  limb 
to  swing',  and  only  after  a  year  or  more  should  he  be  allowed  to  gradually 
bear  weight  upon  the  leg.  If,  however,  excision 
is  done  early,  the  limb  is  fit  for  walking  sooner, 
sometimes  in  five  or  six  months.  If  the  affected 
leg  is  allowed  to  touch  the  ground  too  soon,  it 
becomes  pushed  up  upon  the  dorsum  ilii,  and 
much  shortening  results.  On  the  other  hand, 
if  the  limb  is  fixed  too  long,  it  becomes  stiff. 
A  very  large  proportion  of  cases  of  excision  in 
the  later  stages  of  the  disease  remain  with 
sinuses,  but  often  these  produce  no  ill  result 
except  the  trouble  of  dressing  them  ;  a  certain 
number  may  be  got  to  close  by  scraping,  cautery, 
&c.  ;  others  are  very  intractable.  In  a  certain 
number  of  cases  the  wound  re-opens  after  having 
healed  ;  this  is  undoubtedly  common,  but  is  due 
to  over-use,  neglect,  or  violence,  and  with  ordi- 
nary care  and  frequently  repeated  scrapings  with 
closure  of  the  wound  after  excision  of  tuberculous 
tracks  and  edges  of  skin,  the  wounds  usually 
again  close." 

It  is  interesting  and  important  to  note  that 
in  measuring  the  amount  of  shortening  after 
excision  the  real  shortening — as  measured  from 
the  upper  end  of  the  femur  to  the  malleolus  on 
each  side — is  often  trifling,  and  sometimes 
there  is  none,  while  the  practical  shortening  as 
measured  from  the  pelvis  to  the  malleolus  is 
considerable.      Though    some    shortening   will 

necessarily  result,  any  large  amount  is  due  to  weight  being  borne  upon  the 
limb  prematurely.  It  has  already  been  pointed  out  that  growth  in  length  of  the 
femur  takes  place  almost  entirely  at  its  lower  epiphysial  line  ;  hence  the  loss 
of  length  or  true  shortening  is  only  the  distance  from  the  line  of  section  to 
the  top  of  the  head,  coupled  with  such  arrest  of  growth  as  maj'  result  from 
impaired  nutrition,  this  last  being,  of  course,  a  very  inconstant  quantity. 
Oilier  estimates  that  during  the  first  four  years  of  life  growth  takes  place  about 
equally  at  each  end  of  the  femur  ;  after  that  time  the  lower  end  grows  more 
rapidly. 

The  primary  objects  of  the  operation  of  excision  of  the  hip  are  to  save 
life  and  relieve  pain  ;  the  next  most  important  question  is  that  of  the  useful- 


Fig.  165. —  From  a  photograph 
showing  a  good  average  result 
after  excision,  when  the  leg  has 
been  walked  upon,  and  the 
stump  of  the  femur  is  thrust 
up  upon  the  dorsum  ilii. 


yio  Hip  Disease 

ness  of  the  limb  and  of  the  condition  of  the  'joint'  after  the  operation.  One 
of  two  results  must  occur  after  excision  :  either  a  freely  movable  limb,  or  one 
with  varying  degrees  of  stiffness,  from  some  mobility  to  bony  ankylosis. 
Bony  ankylosis  after  excision  is  very  rare.  Close  fibrous  union,  so  that  but 
little  mobihty  remains,  is  very  common  ;  movement  through  from  30°  to  50° 
is  perhaps  the  commonest  result,  and  a  smaller  number  have  complete 
mobility. 

It  is  not  possible  to  estimate  in  figures  the  results  to  be  expected  from 
excision  ;  for  details  we  must  refer  to  the  monograph  mentioned  at  the 
beginning  of  the  chapter. 

Whether,  then,  we  consider  the  pathology  of  the  disease,  the  actual  local 
condition,  the  relief  of  pain,  the  preservation  of  life,  the  duration  of  illness, 
the  condition  of  the  limb  and  its  usefulness,  or  the  dangers  of  secondary 
disease,  on  every  ground,  in  our  opinion,  excision  is  the  best  course  under 
the  circumstances  and  with  the  limitations  already  stated. 

Chronic  Synovitis  of  Adolescents. — Occasionally  in  young  rapidly 
growing  lads  or  girls,  usually  from  12  to  17  years,  a  chronic  synovitis  of 
the  hip  occurs  often  apparently,  due  to  strain  or  long  standing.  It  causes 
pain,  lameness,  and  some  stiffness  of  the  joint  with  effusion,  but  Httle  or  no 
swelling  around  the  trochanter,  though  this  may  appear  prominent.  The 
softening  of  the  ligaments  by  the  inflammation  may  lead  to  complete  or  partial 
dislocation  of  the  head  of  the  femur.  We  believe  we  have  seen  this  condition 
associated  with  coxa  vara.  The  treatment  is  prolonged  rest,  and  the  pro- 
spect of  recovery  is  good,  though  some  stiffness  may  remain  for  a  long  time. 

Conclusions.  —  i.  The  hip  joint  in  childhood  is  commonly  subject  to  two 
affections  :  {a)  simple  synovitis  ;  {b)  tubercular  disease. 

2.  Simple  synovitis  is  usually  traumatic,  very  rarely  suppurates,  is  amen- 
able to  ordinary  treatment,  and  as  a  rule  leaves  behind  no  bad  results. 

3.  Tubercular  disease,  or  common,  '  hip  disease,'  affects  primarily  the 
upper  end  of  the  femur,  or  occasionally  the  acetabulum,  and  produces  necrosis 
or  extensive  caries. 

4.  In  the  earher  stages  of  hip  disease,  before  caseation  of  bone  or  suppura- 
tion has  taken  place,  proper  treatment  will,  in  a  fair  proportion  of  cases, 
result  in  recover)'  with  a  nearly  perfect  limb. 

5.  As  soon  as  suppuration  occurs,  it  is  certain  that  recovery  will  not 
take  place  without  destruction  of  the  upper  epiphysis  of  the  femur  more  or 
less  completely. 

6.  The  process  of  removal  of  the  diseased  bone  without  operation  is  so 
slow,  so  exhausting,  and  so  uncertain  that  it  should  be  reserved  for  those 
cases  where  time  and  care  can  be  fully  devoted  to  it. 

7.  A  case  of  hip  disease,  seen  before  suppuration  has  occurred,  is  best 
treated  by  the  use  of  a  Thomas's  splint  with  or  without  previous  straightening" 
by  extension. 

8.  Excision  of  the  hip  cuts  short  the  disease,  relieves  pain,  and  gives  a 
better  limb  than  the  average  result  obtained  without  operation  in  cases  of 
equal  severity. 

9.  Excision  should  be  looked  upon  as  an  ordinary  operation  for  necrosis, 
and  the  operation  itself  is  not  necessarily  attended  by  a  higher  mortality  than 
sequestrotomy  elsewhere. 


Summary  7 1 1 

10.  Excision  in  old  pelvic  disease,  or  where  the  health  is  broken  down, 
or  the  patient  is  over  fifteen  years  of  age,  should  usually  be  rejected  in  favour 
of  amputation. 

1 1.  The  presence  of  a  sinus  after  operation,  unless  there  is  much  discharge 
or  evidence  of  extensive  pelvic  disease,  does  not  imply  failure  of  the  operation. 

12.  The  presence  of  an  abscess  after  a  long  period  of  quiescence  (resi- 
dual abscess),  without  other  evidence  of  relapse,  is  not  to  be  looked  upon  as 
of  serious  import. 

Ainputation. — The  question  of  amputation  at  the  hip  joint  for  disease  is 
one  of  the  highest  importance.  We  must  consider  not  only  the  unavoidable 
mortality  and  crippling  caused  by  the  disease,  but  also  the  interference  with 
pleasure  and  education  entailed  by  long  confinement  indoors.  WTiere  there 
is  no  reasonable  prospect  of  recovery  with  a  useful  limb,  amputation  must 
not  be  too  summarily  set  aside. 

There  is  little  doubt  that,  in  cases  of  extensive  disease  where  the  femur 
is  necrosed  for  a  long  distance  and  the  powers  of  the  patient  are  madequate 
to  repair  it,  in  cases  where  descending  osteomyelitis  occurs,  and  in  cases 
where  profuse  discharge  and  amyloid  disease  come  on,  amputation  should 
be  performed. 

In  cases  of  more  advanced  amyloid  disease,  unless  the  powers  of  the 
child  are  so  enfeebled  that  the  operation  wdll  prove  fatal  by  shock,  it  ought 
also  undoubtedly  to  be  done. 

In  another  class  of  cases  the  question  is  more  difficult.  Where  there  is 
disease  of  the  pelvis,  is  amputation  contra-indicated  if  other  conditions  re- 
quire it  ?  We  should  answer  yes,  if  the  pelvic  disease  extends  so  widely 
that  there  is  no  hope  of  removing  it  all,  and  the  condition  is  one  of  caries  and 
not  necrosis.  Where  there  is  caries  limited  to  the  neighbourhood  of  the 
acetabulum,  where  there  is  necrosis,  or  where  there  is  reason  to  think  that 
the  disease  in  the  limb  is  preventing  repair  in  the  pelvis,  amputation  should 
be  perform'ed. 

As  to  the  question  of  saving  life,  amputation  at  the  hip  performed  with 
due  precautions  as  to  haemorrhage  and  shock,  and  special  care  during  the 
first  twenty-four  hours,  is  by  no  means  a  fatal  operation  in  children. 

We  have  amputated  in  some  fifteen  cases  in  children.  In  nearly  all 
excision  had  been  previously  performed.  All  of  these  recovered  well  from 
the  operation  except  one  who  died  from  haemorrhage. 

The  best  plan  is  the  oval  incision  of  Furneaux  Jordan  ;  the  excision 
wound  should  be  utilised,  and  the  line  of  section  brought  as  far  as  possible 
from  the  anus  and  vulva. 

Neither  the  various  methods  of  operation  nor  the  best  means  of  con- 
trolling bleeding  are  questions  suited  for  discussion  here.  Elevating  the 
limb  before  operation,  and  digital  pressure  with  the  help  of  an  elastic  tour- 
niquet in  the  early  stages  of  the  operation,  are  as  efficient  means  of  control- 
ling the  hjemorrhage  as  any  ;  in  several  cases  we  have  ligatured  the  femoral 
or  external  iliac  as  a  preliminary,  and  think  well  of  this  plan. 

If  possible,  it  is,  as  pointed  out  by  iMr.  Shuter,  well  to  preserve  as  much 
periosteum  as  possible,  and  it  will  be  found  that  afier  excision  the  bone 
usually  very  readily  separates  from  the  periosteal  sheath  ;  a  longer,  firmer, 
and  more  or  less  mobile  stump  may  be  thus  obtained. 


712  Hip  Disease 

Double  Hip  Disease  is  not  a  very  rare  condition,  and  we  have  more  than 
once  had  cases  in  which  the  second  joint  has  become  diseased  while  the 
child  was  lying  in  bed  for  the  treatment  of  the  first  joint.  The  management 
of  these  cases  is  that  of  the  common  condition,  except  that  a  double  Thomas's 
splint  is  of  course  required.  Double  excision  is  occasionally  called  for,  and 
we  have  had  good  results  from  it ;  in  one  case  the  child  remains  sound  and 
well,  and  is  able  to  walk  without  support. 

Scissor-leg'g'ed  Deformity  after  Hip  Disease. — Mr.  Lucas,  Dr.  Tyson 
of  Folkestone,  and  others  have  recorded  cases  where,  as  a  result  of  double 
hip  disease,  a  peculiar  'cross-legged'  or  '  scissor-legged  deformity'  occurs  ; 
both  legs  are  adducted,  the  one  in  front  of  the  other,  and  progression  takes 
place  entirely  by  movement  at  the  knee  joint.  It  is  easy  to  understand  the 
condition  by  simply  walking  with  the  knees  crossed  over  one  another.  It 
occurs,  according  to  i\lr.  Lucas,  in  cases  where  disease  has  taken  place  first 
in  one  joint,  resulting  in  adduction,  and  then  subsequently  in  the  other  joint. 
Other  deformities  may  result  from  the  same  condition. 

Adduction  after  Subsidence  of  Hip  Disease. — -This  is  unfortunately  a 
common  and  most  troublesome  cause  of  crippling  after  active  disease  has 
subsided.  It  results  from  inadequate  treatment  while  the  disease  is  active, 
or  premature  removal  of  splints  ;  also  very  often  from  the  bad  habit  these 
patients  acquire  of  resting  the  foot  of  the  affected  limb  upon  the  dorsum  of 
the  other  foot.  The  deformity  may  in  some  cases  be  remedied  by  extension 
either  direct  or  at  right  angles,  but  in  severe  and  rigid  cases  it  may  be 
necessary  to  osteotomise  the  upper  end  of  the  femur  with  or  without  division 
of  the  adductors  before  the  limb  can  be  straightened. 

Note. — Our  former  Senior  Resident,  Dr.  Carruthers,  now  of  Congleton,  has  kindly 
gone  over  our  records  of  excision  of  tlie  hip  from  1886  to  1893  performed  by  the  v/riter. 
He  reports  that  83  operations  liave  been  done,  of  which  in  31  instances  the  wound  was 
sutured  without  drainage.  Of  these  22  healed  at  once,  i.e.  by  primary  union  throughout, 
or  with  the  exception  of  small  superficial  areas  ;  9  cases  failed  to  unite  at  once,  and  5  of 
the  22  which  united  broke  down  again  after  varying  periods.  These  figures  must  be  taken 
as  approximate  only,  inasmuch  as  wounds  may  have  re-opened  shortly  after  discharge,  and 
in  one  or  two  cases  of  the  83  the  result  is  doubtful. 


7^':, 


CHAPTER   XXXII 

SPINAL   DISEASE 

Caries  of  the  Spine,  Angular    Curvature,  and  Pott's  Disease,   are 

terms  which,  as  commonly  used,  include  conditions  of  very  varying  severity 
affecting  several  dififerent  structures.  This  is  so,  since  the  spinal  column  is 
in  each  segment  provided  with  several  dififerent  articulations,  and  any  of 
these,  as  well  as  the  bone  itself,  may  become  the  seat  of  disease.  Thus  the 
mischief  may  begin  at  the  junction  of  a  vertebral  body  and  intervertebral  disc, 
at  the  junction  of  a  vertebral  body  with  its  epiphysis,  in  the  centre  of  a  body, 
or  on  its  anterior,  posterior,  or  lateral  surfaces  ;  or,  again,  the  articular  pro- 
cesses, or  their  joints,  the  transverse  and  spinous  processes,  may  any  of 
them  be  separately  diseased.  Again,  the  mode  of  connection  between  the 
skull  and  atlas,  the  atlas  and  axis,  and  the  sacral  joints  implies  necessarily 
varying  conditions  from  those  found  in  disease  of  the  rest  of  the  column. 

Obviously  the  names  given  to  disease  of  the  spine  are  not  equally 
applicable  to  all  these  afifections  ;  disease  of  a  spinous  or  an  articular  pro- 
cess does  not  give  rise  to  angular  curvature.  It  is,  however,  quite  the  ex- 
ception to  find  in  children  disease  of  the  spine  affecting  any  part  except  the 
bodies  and  intervertebral  discs  ;  we  can  only  call  to  mind  two  cases  of  disease 
of  a  spinous  process  alone,  one  of  which  was  the  following  : 

Case. — Necrosis  of  the  Cervical  Spinous  Processes. — Edward  H. ,  age  4  years  5  nionths  ; 
admitted  July  21,  1882.  Si.x  weeks  ago  a  hard  lump  was  noticed  at  the  back  of  the  neck, 
he  having,  a  fortnight  before,  fallen  on  the  back  of  his  head  ;  the  swelling  had  gi-adually 
increased,  but  he  had  had  neither  pain  nor  tenderness.  On  admission  he  was  well  nou- 
rished ;  there  was  a  large  fluctuating  swelling  in  the  middle  of  the  back  of  the  neck  ;  it  was 
opened  antiseptically,  and  about  dr.  iij  of  healthy  pus  escaped  ;  the  tips  of  one  or  more 
spines  were  bare  ;  the  dressing  slipped  the  ne.xt  day  ;  the  abscess  continued  to  discharge, 
and  he  was  sent  out  on  August  25  with  a  jurymast  on  and  a  still  unhealed  sinus.  In  January 
1883,  at  Out  Patients',  he  was  nearly  well :  the  movements  of  the  neck  were  perfect  and  the 
thickening  nearly  gone,  but  there  was  still  a  small  sinus.  Subsequently  a  sequestrum 
consisting  of  the  spinous  process  was  removed,  and  he  quite  recovered  [vide  Chapter  on 
Diseases  of  the  Bones). 

We  have  never  verified  a  case  of  disease  of  a  joint  between  the  articular 
processes,  and  disease  of  the  transverse  processes  is  rare.  The  atlanto-axial 
and  occipito-atlantoid  joints  are  also  very  rarely  afifected  in  children  in  com- 
parison with  caries  of  the  bodies. 

The  ordinary  form  of  caries  of  the  spine  affecting  the  bodies  or  interverte- 
bral discs  or  both  structures  is  met  with  in  all  parts  of  the  spinal  column 
from  the  axis  to  the  sacrum.  In  a  hundred  cases  taken  at  random  from  our 
Out-Patient  papers  we  found  eighteen  cases  of  cervical  disease,  forty-one 
cases  where  the  cervico-dorsal,  upper,  or  mid-dorsal  regions  were  involved. 


714 


Spinal  Disease 


thirty-three  instances  of  lower  dorsal  or  dorso-lumbar  disease,  six  of  lumbar 
caries,  and  two  of  disease  of  the  sacrum.  R.  W.  Parker,  as  quoted  by 
Erichsen,  gives  the  following  figures  :  Cervical  nine,  dorsal  eighty-two, 
dorso-lumbar  twenty-one,  lumbar  or  lumbo-sacral  thirty-seven,  out  of  149 
cases.  These  figures  are  of  some  importance,  for,  in  the  first  place,  no 
attempt  at  removal  of  diseased  bone  can  be  made  in  the  dorsal  region,  and 
only  exceptionally  in  the  cervical  part  of  the  spine,  while  the  treatment  of 
the  disease  by  apparatus  becomes  more  troublesome  as  we  ascend  from  the 
mid-dorsal    region.     Pus    is    more  likely  to  point  externally  as  lumbar  or 

psoas  abscess  when  the  lower  dorsal 
^^^-  \  or    lumbar    vertebrae    are    attacked, 

though  it  is  not  rare  for  dorsal 
abscesses  to  track  down  the  spine. 
Cervical  abscesses  point  in  the  pha- 
rynx or  side  of  the  neck.  Lastly, 
occasionally  two  foci  of  disease  exist, 
as  in  fig.  166. 

Pathology. — It    is    probable     that 
^^  __^     ^  ^       caries    of   the    spine    begins     nearly 
^^^g'  ^^^^£^       always  in   the  body  of  the   vertebra, 

'^^  '"  and  not  in  the  intervertebral  disc 
itself ;  but  it  is  difficult  to  be  sure  of 
the  relative  frequency  of  these  sites, 
for  the  mischief  soon  spreads  beyond 
the  limits  of  a  vertebra  in  most  in- 
stances. Erichsen  considers  the  epi- 
physial lines,  the  front  of  the  bodies, 
and  the  centre  of  the  bodies  to  be  in 
this  order  the  most  frequent  primary 
seats  of  disease.  Wilks  and  Moxon 
apparently  incline  to  the  belief  that 
the  bones  are  the  primary  seat  of 
'  scrofulous '  disease  in  children,  while 
disease  beginning  in  the  discs  is  a 
separate  type  of  lesion — at  all  events 
in  some  cases  the  result  simply  of 
injury ;  probably  the  seat  of  disease 
varies.  In  most  cases  the  lesion  is 
an  ordinary  tuberculous  disease  of 
rarefying  ostitis  being  found  in  some  parts,  while  in  others  caries 
necrotica  or  more  extensive  necrosis  exists.  Although  a  large  number  of 
patients,  the  subject  of  caries  of  the  spine,  never  develop  external  abscesses, 
it  by  no  means  follows  that  no  suppuration  takes  place  ;  large  collections  of 
pus  may  form  beneath  the  anterior  common  ligament  in  the  dorsal  region 
without  ever  discharging,  and  may,  like  abscesses  elsewhere,  dry  up  and 
remain  as  cheesy  or  calcareous  masses.  More  rarely  the  abscess  may  empty 
itself  into  the  lung  or  intestine  ;  the  latter  result  we  have  seen  in  a  case  of 
lumbar  caries  and  in  sacral  disease,  and  it  is  probably  more  common  than  is 
supposed,  the  pus  in  the  motions  being  overlooked  or  put  down  to  enteritis. 


Fig.  166. 


bone, 


-Caries  of  the  Spine,  showing  two 
foci  of  disease. 


A  bscess — Deformity  7 1 5 

In  other  instances  caries  of  the  spine,  hke  caries  elsewhere,  may  be  through- 
out unattended  with  any  pus  formation  (caries  sicca). 

There  is  often  a  discharge  of  small  sequestra  from  spinal  abscesses,  and 
sometimes  fair-sized  pieces  of  dead  bone  come  away  or  are  extracted,  but 
this  is  not  common  ;  as  in  the  well-known  instances  of  the  odontoid  process 
coming  away  entire  through  the  pharynx. 

Pus  from  a  lesion  in  one  part  of  the  spine  may  track  downwards  and  give 
rise  to  a  second  focus  of  disease  lower  down,  but  sometimes,  as  in  fig.  i66, 
the  two  foci  are  quite  independent  and  isolated  from  each  other  ;  in  the 
case  from  which  the  figure  was  taken  the  lower  patch  of  disease  developed 
first. 

In  some  instances  disease  may  begin  as  a  simple  non-tuberculous 
intiammation,  the  result  of  injury  as  already  mentioned  ;  this  is  not,  however, 
common  in  children  in  our  experience,  since  in  them  the  disease  usually 
runs  the  course  of  tuberculous  lesions  generally.  Cases  of  spinal  curvature, 
due  to  the  lesions  of  congenital  syphilis,  are  also  described. 

Abscess. — Pus  in  connection  with  spinal  caries  usually  burrows  along 
certain  definite  lines  determined  by  muscular  and  fascial  barriers  ;  thus  in  the 
neck,  abscesses  are  either  prsevertebral,  bulging  forwards  into  the  pharynx, 
as  in  atlanto-axial  disease,  or  point  at  the  side  in  the  posterior  triangle,  just 
behind  the  sterno-mastoid,  sometimes  on  both  sides. 

In  the  lower  cervical  and  upper  dorsal  regions  the  abscesses,  if  they  exist, 
rarely  point  externally,  but  if  they  do  so  either  track  down  the  spine  and 
appear  as  lumbar  or  psoas  abscesses,  or  perforate  an  Intercostal  or  intertrans- 
verse space  and  appear  in  the  back.  Abscess  in  upper  dorsal  caries  com- 
paratively rarely  points  externally.  Dorsal  and  lumbar  caries  commonly 
gives  rise  to  psoas  abscess,  the  pus  getting  into  the  sheath  of  the  muscle  at 
its  upper  attachment  and  burrowing  down  within  it,  often  entirely  destroying 
the  muscle  itself ;  it  then  may  either  pass  outwards  into  the  iliac  fossa, 
beneath  the  iliac  fascia,  and  form  a  swelling  there  (iliac  abscess),  or,  travelling 
on  beneath  Poupart's  hgament,  bulge  in  the  thigh  on  the  outer  side  of  the 
femoral  sheath  as  a  psoas  abscess.  Often,  however,  though  forming  a  col- 
lection in  front,  the  matter  does  not  point  there,  but,  passing  on  behind  the 
vessels  towards  the  lesser  trochanter,  appears  at  the  back  of  the  thigh  as  a 
gluteal  abscess.  In  other  instances  the  pus  finds  its  way  round  the  edge  of 
the  quadratus  lumborum  and  through  the  transversalis  aponeurosis,  perhaps 
in  the  course  of  a  branch  of  a  lumbar  artery,  and  points  in  the  back  (lumbar 
abscess).  Again,  the  pus  may  gravitate  backwards  into  the  pelvis  and  escape 
through  the  sciatic  notch,  appearing  as  another  form  of  gluteal  abscess.  We 
have  seen  an  abscess  bulging  at  both  sciatic  foramina,  so  that  fluctuation 
could  be  felt  across  the  cavity  of  the  pelvis.  Less  often  the  abscess  descends 
over  the  iliac  crest  on  its  outer  aspect,  or  burrows  forwards  between  the 
layers  of  the  abdominal  wall.  Once  it  has  reached  the  thigh,  matter  may 
track  down  it  for  an  indefinite  distance. 

Deformity. — In  most  cases  caries  of  the  spine  sooner  or  later  gives  rise 
to  angular  deformity  (kyphosis).  This  is,  of  course,  due  to  destruction  of 
the  bodies  of  one  or  more  vertebrae,  and  consequent  collapse  of  the  column  ; 
or  possibly,  to  a  certain  extent,  is  caused  by  muscular  contraction  drawing 
together  the  adjacent  bodies,  the    spines  being  thereby  made    to  project 


7i6  Spinal  Disease 

posteriorly.  The  amount  of  deformity  in  such  cases  varies  from  a  mere  faint 
prominence  of  one  vertebral  spine,  only  to  be  i-ecognised  by  careful  observa- 
tion, to  a  great  prominent  'knuckle'  involving  six  or  eight  vertebree.  When 
the  disease  is  in  the  dorsal  region,  the  falling  together  of  the  vertebral  bodies 
produces  a  corresponding  chest  deformity  ;  the  ribs  are  brought  close 
together,  the  shoulders  are  raised,  and  the  head  looks  sunken  between  them, 
the  antero-posterior  diameter  of  the  chest  being  increased  at  the  expense  of 
the  vertical. 

In  the  cervical  region  the  deformity  is  usually  much  less  marked  ;  some- 
times, however,  there  is  a  prominent  angular  curvature,  and  the  head  is 
drooped  forwards  with  the  chin  upon  the  sternum  ;  or  the  head  and  upper 
cervical  vertebrae  are  poked  forwards  with  a  projection  backwards  at  the 
root  of  the  neck. 

It  must  be  remembered,  however,  that  these  deformities  occur  only  in 
an  advanced  stage  of  destruction,  and  only  when  the  whole  breadth  of  a 
vertebra  is  eaten  away  ;  thus,  disease  of  one  side  or  the  posterior  part  of  a 
body  may  exist  without  any  angular  deformity,  and  in  some  instances  the 
spine  is  recurved,  so  that  the  convexity  is  forwards  instead  of  backwards  ; 
this  is  most  commonly  seen  in  the  cervical  region  :  we  have,  however,  seen 
it  in  the  lumbar  vertebrse  too.  In  such  cases  the  bending  is  never  sharply 
angular,  but  is  due  to  spasm  of  the  posterior  spinal  muscles  ;  it  can  rarely, 
if  ever,  be  due  to  desti'uction  of  bone,  for  to  produce  such  result,  not  only 
the  bodies  but  the  arches  of  the  vertebrae  would  have  to  be  destroyed  :  the 
condition  is  generally  mei'ely  an  exaggeration  of  the  normal  curves. 

Since  there  is  a  physiological  curve  with  its  convexity  forwards  in  the 
cervical  and  lumbar  regions,  a  certain  amount  of  destruction  of  the  vertebral 
bodies  has  the  effect  of  merely  straightening  these  curves,  and  it  is  only 
when  considerable  erosion  has  taken  place  that  a  curve  with  its  convexity 
backwards  is  produced. 

Extensive  disease  of  the  posterior  parts  of  the  bodies  may,  of  course, 
exist  without  any  curvature,  and  in  such  cases  the  inflammatory  material 
poured  out  may  produce  pressure  on  the  cord  or  nerves,  or  inflammation 
by  extension  ;  hence  the  old  saying,  '  The  less  the  deformity,  the  more  the 
paralysis.'  ^  Paralysis  in  such  cases  is  probably  hardly  ever  due  to  bony 
pressure,  since  the  spinal  canal  is  not  encroached  upon ;  this  is  only  likely  to 
occur  where  a  sequestrum  is  pushed  into  the  canal.^  Lateral  curvature 
sometimes  results  from  destruction  of  the  sides  of  the  bodies  and  consequent 
collapse  ;  more  often,  however,  any  lateral  curvature  that  does  exist  is  a  result 
of  ligamentous  and  muscular  weakness,  and  as  such  is  a  true  lateral  curvature. 

-Before  there  is  any  permanent  deformity  from  loss  of  material,  certain 
characteristic  attitudes  are  assumed  by  the  subjects  of  spinal  disease.  In 
caries  of  the  cervical  spine  the  child  often  supports  his  head  with  his  hands, 
to  lighten  the  pressure  upon  the  diseased  spot  and  prevent  any  sudden  jar, 
and  is  slow  and  careful  in  turning  round  and  stooping.  Where  the  dorsal  or 
lumbar  regions  are  involved,  instead  of  bending  the  spine  to  reach  any  object 

1  It  is  also  a  matter  of  frequent  observation  that  paraplegia  and  abscess  are  rarely 
associated. 

2  Paraplegia  is  commoner  in  cervical  and  upper  dorsal  caries  than  in  disease  lower 
down. 


Defon)iity  in  Spinal  Caries  yiy 

upon  the  floor,  the  cliild  bends  the  knees  and  hips,  and  so  brings  down  the 
hands,  and  at  every  opportunity  assumes  the  resting  position  shown  in  fig.  167. 

It  is  most  important  to  distinguish  angular  curvature  from  lateral  curva- 
ture and  from  rickety  spine.  It  is  only  in  the  very  early  and  very  late 
stages  of  disease  that  there  is  likely  to  be  any  doubt  whether  a  case  is  one 
of  lateral  or  angular  curvature  ;  in  ordinary  well-marked  cases  the  distinc- 
tion is  clear  enough.  In  some  old  cases  of  lateral  cui-vature  very  sharp 
bends  in  the  spine  are  much  like 
angular  deformity  ;  and  again,  we 
have  more  than  once  seen  cases 
where  there  was  an  early  lateral 
curve  and  no  symptoms  pointing  to 
caries,  yet  in  a  few  months  un- 
doubted caries  appeared.  Careful 
and  repeated  observations  are,  there- 
fore, necessary  if  there  is  any  possi- 
bility of  doubt,  and  it  must  be  re- 
membered that  the  two  affections 
may  co-exist.  Ordinarily  a  diagnosis 
is  readily  made  by  the  presence  in 
the  one  of  a  lateral  curve  and  of 
rotation,  and  by  the  fact  that  the 
curve  in  caries  is  abrupt,  in  lateral 
curvature  gradual,  as  well  as  by  the 
presence  or  absence  of  the  other 
symptoms  of  caries  mentioned.^ 

The  rickety  spine  is  distinguished 
by  its  being  a  general  rounded  curve, 
by  the  absence  of  rigidity,  by  the 
disappearance  of  the  curve  when  the 
child  is  held  so  that  the  weight  comes 
upon  the  spine,  by  the  evidences  of 
rickets  elsewhere,  and  the  absence  of 
the  characteristics  of  caries.     Caries 


Fig.  167. — Caries  of  the  Spine,  showing  a  cha- 
racteristic resting  attitude,  which  sliould  be 
contrasted  with  the  rickety  spine  seen  in  fig.  38. 


also  is  very  rare  in  the  first  two  years  of  life,  rickety  spine  much  more 
common  during  that  period. 

With  these  exceptions,  and  the  possible  ones  of  an  old  fracture  or  dis- 
location, or  congenital  undue  prominence  of  certain  spines,  or  the  develop- 
ment of  bursce  over  the  spines,  the  result  of  friction  or  pressure,  angular 
deformity  may  be  taken  as  pathognomonic  of  caries  either  present  or  pre- 
existing. 

Abscess  is  not  by  itself  a  certain  indication,  since  it  may  be  due  to  many 
other  causes  than  spinal  caries  ;  still,  the  presence  of  a  lumbar,  gluteal,  iliac, 
psoas,  post-pharyngeal,  or  cervical  abscess  should  always  lead  to  a  caieful 
examination  of  the  spine.  It  must  be  remembered  that  pelvic  disease, 
glandular,  perityphlitic,  perisigmoid,  and  perinephritic  abscesses,  empyema, 
carious  ribs,  sacro-iliac  and  hip  disease,  &c.,  may  give  rise  to   suppuration. 


1  See  also  a  paper  by  Lovett  of  New  York,  lE 


7i8  Spinal  Disease 

which  may  point  in  positions  identical  with  those  in  which  spinal  abscesses 
may  find  outlet. 

Rigidity  is  a  most  important  sig'n  of  spinal  disease,  important  all  the 
more  because  it  is  an  early  one  ;  the  stiffness  is  due  to  spasm  of  the  spinal 
muscles,  just  as  in  disease  of  any  other  joint.  Rigidity  is  best  tested  by 
stripping  the  child  and  putting  some  object  upon  the  floor  for  him  to  pick 
up  ;  by  w^atching  carefully  it  will  be  seen  whether  the  whole  spine  bends  as 
in  health,  or  whether  it  is  held  stiff  and  immovable  in  any  part.  Healthy 
children  freely  bend  their  spines,  but  in  order  to  fully  test  the  mobility  of  the 
column  the  child  should  be  told  to  keep  its  knees  straight.  Absence  of 
flexibility  is,  taken  alone,  the  most  valuable  sign  of  caries  except  deformity. 

In  the  cervical  region,  muscular  spasm  may  give  rise  to  wryneck,  in- 
ability to  nod  or  to  turn  the  head  round,  according  to  the  part  involved. 

Besides  contraction  of  the  posterior  spinal  muscles,  there  may  be  rigidity 
of  the  ilio-psoas,  causing  flexion  of,  and  inability  to  straighten,  one  or  both 
legs  :  this  usually  means  that  a  psoas  abscess  is  beginning  to  form,  and  the 
muscles  are  rigid  in  consequence  of  irritation,  or  kept  voluntarily  contracted 
to  prevent  pressure  upon  the  abscess.  Local  rigidity  of  the  lumbar  muscles 
or  of  certain  of  the  posterior  spinal  muscles  will  sometimes  be  found  ;  thus 
the  erector  spinse  may  be  seen  tightly  contracted  and  standing  out  promi- 
nently just  above  the  sacrum. 

The  test  of  bending  the  body  backwards  is  more  applicable  to  adults  than 
to  children,  in  whom  it  is  difficult  to  estimate  amounts  of  pain  ;  it  should, 
however,  always  be  employed. 

Muscular  wasting  occurs  in  spinal  as  in  other  joint  diseases,  but  is  rarely 
well  marked,  except  when  the  disease  is  far  advanced,  and  hence  is  not  of 
great  value  alone  as  a  symptom. 

Dysphagia  may  result  from  pressure  by  an  abscess  upon  the  pharynx  or 
oesophagus,  or  dyspnoea  from  pressure  upon  the  trachea  or  lungs  or  upon  the 
recurrent  laryngeal  nerves  in  disease  lower  down  ;  so  too,  possibly,  extensive 
abscess  in  the  chest  may  give  rise  to  physical  signs,  dulness,  &c.  This  is, 
however,  more  likely  to  be  due  to  enlarged  mediastinal  glands.  We  have 
recently  had  a  case  in  which  severe  and  progressive  dyspnoea  came  on  in  a  boy 
with  acute  caries  of  the  upper  dorsal  spine  ;  the  disease  was  only  of  about  seven 
weeks'  standing,  but  there  was  a  well-marked  angular  curvature.  There  was 
no  paraplegia.  Slight  dulness  was  found  on  the  right  side  near  the  spine, 
but  no  evidence  of  actual  lung  mischief  sufficient  to  account  for  the  dyspnoea. 
A  portion  of  rib  opposite  the  most  prominent  part  of  the  curvature  was 
excised  and  the  head  and  proximal  part  of  the  rib,  which  were  carious,  removed. 
A  considerable  '  abscess '  was  found  in  front  of  the  spine,  and  all  the 
pressure  symptoms  were  at  once  relieved  when  it  was  emptied. 

Larg'e  abdominal  abscesses  may  produce  pressure  effects  upon  vessels 
and  viscera,  but  these  are  rare  results.  Abdominal  distension  from  flatu- 
lence may  be,  due  either  to  pressure  upon  nerves  or  to  failure  of  the  digestive 
powers  in  later  stages,  or  to  coincident  tubercular  disease  of  the  intestines, 
mesenteric  glands,  &c. 

The  subjective  symptoms  of  spinal  caries  are  pain  and  loss  of  sensation. 
Pain  may  be  acute  or  nothing  more  than  a  feeling  of  tiredness  or  aching  ;  it 
is  usually  an  early  and  prominent  symptom  ;  it  may,  however,  be  entirely 


Symptoms  of  Spinal  Caries  719 

absent,  just  as  in  some  instances  of  chronic  joint  disease  elsewhere.  Usually 
there  is  pain  over  the  affected  spot,  increased  by  pressure  or  jarring  of  the 
spine,  such  as  may  occur  in  jumping,  or  suddenly  stepping  down  from  a 
height  ;  in  caries  of  the  cervical  spine,  pressure  upon  the  top  of  the  head 
often  causes  suffering,  and  in  any  part  of  the  column  flexion  or  rotation 
movements  may  be  painful. 

Further,  there  is  usually  pain  in  the  course  of  the  nerves  passing  out 
from  the  diseased  area  ;  thus,  in  dorsal  caries  there  is  pain  at  the  sternum 
or  in  the  side  ;  in  dorso-lumbar  disease  there  is  abdominal  pain  ('  girdle 
pain  ; '  so  called  '  dry  belly  ache ').  Pains  in  the  limbs,  shooting  down  the 
legs  over  the  distribution  of  the  sacral  and  lumbar  plexuses,  and  similarly  in 
the  arms,  may  be  met  with.  Any  obscure  pain  should  always  be  carefully 
traced  to  its  source  by  searching  along  the  whole  course  of  the  affected  nerve 
up  to  its  origin.  Thus,  pain  in  the  back  of  the  head,  so  called  '  headache,' 
may  be  due  to  pressure  upon  the  occipital  nerves,  and  so  on.' 

The  anaesthesia  and  parassthesia  due  to  spinal  caries  are  either  the  result 
of  pressure  upon  the  theca  or  nerves  or  of  inflammation  spreading  from  the 
bone  to  the  meninges  or  cord,  and  will  be  found  described  at  page  573. 

Pain  in  the  spine  is  sometimes  increased  by  the  application  of  warmth, 
e.g.  a  hot  sponge  applied  over  the  diseased  part,  but  the  symptom  is  not 
constant  nor  of  any  great  value.  In  some  instances  we  have  found  herpes 
zoster  occurring  in  connection  with  caries  of  the  spine,  and  it  is  worth  while 
to  examine  the  spine  in  cases  of  shingles,  since  the  erruption  may  be  a  result 
of  lesions  starting  in  the  spinal  column. 

The  conditions  most  likely  to  be  confounded  with  spinal  disease  are,  in 
the  neck,  sprains  or  stiff  neck  from  cold,  reflex  irritation,  &c.,  glandular 
inflammation,  and  cervical  cellulitis.  The  '  vertebra  prominens  '  should  be 
remembered,  and  the  ease  with  which  the  cervical  transverse  processes  can 
be  felt  ;  there  is  often  a  deceptive  feeling  of  thickening  about  the  cervical 
vertebrte  which  is  apt  to  mislead  unless  comparison  is  made  with  a  healthy 
neck.  In  caries  thickening  will  be  felt  In  glandular  abscess  the  glands 
themselves  can  usually  be  felt  to  be  enlarged,  and  generally  the  pain  is 
most  marked  or  only  exists  on  one  side,  whereas  in  caries  there  is  usually 
tenderness  on  pressure  on  both  sides.  This,  with  the  other  symptoms  already 
mentioned,  will  serve  to  distinguish  between  the  two  conditions.  Prsever- 
tebral  abscess,  though  often  due  to  spinal  disease,  may  be  the  result  of 
several  other  lesions  ;  vide  p.  78. 

Caries  of  the  dorsal  and  lumbar  spine  has  already  had  its  distinguishing 
features  pointed  out  ;  it  is  only  necessary  to  add  that  in  all  cases  search 
should  be  made  for  evidence  of  abscess  deep  in  the  abdomen,  since  large 
collections  of  matter  sometimes  form  very  insidiously. 

Complications. — In  addition  to  the  troubles  arising  directly  from  the 
spinal  lesions  other  complications  may  arise  ;  thus  the  vertebral  disease  may 
be  only  a  part  of  a  general  tuberculosis  in  which  viscera  or  bones  and  joints 
other  than  the  spine  may  be  involved.  Sometimes  a  psoas  abscess  in  track- 
ing down  gives  rise  to  disease  of  the  sacro-iliac  or  hip  joints  {vide  Hip 
Disease).     As  a  result  of  pressure  upon  or  inflammation  of  the  spinal  cord 

''  For  illustrations  of  these  peripheral  pains  the  reader  is  referred  to  Mr.  Hilton's 
admirable  book,  Rest  and  Pain,  edited  by  Mr.  Jacobson. 


720  Spznac  Disease 

and  its  membranes  cystitis  or  paralysis  of  the  bladder  may  result  ;  bedsores 
may  form,  both  as  a  consequence  of  pressure  and  from  the  nerve  lesions. 
Exhaustion,  hectic,  lardaceous  disease,  and  general  tuberculosis  are  the 
most  common  causes  of  death,  though  it  must  not  be  forgotten  that  sudden 
death  may  occur  from  displacement,  the  result  of  softened  ligaments,  in  the 
upper  cervical  spine,  or  from  bursting  of  an  abscess  into  the  air  passages,  or 
ulceration  into  a  large  vessel.  In  other  instances  pyaemia  or  other  inter- 
current disease  cuts  life  short. 

Paraplegia  may  occur  in  the  course  of  spinal  disease  as  a  result  of  pres- 
sure from  inflammatory  exudation  poured  out  into  the  spinal  canal,  from 
effusion  pressing  upon  the  nerve  roots,  an  occurrence  met  with  in  the  cervical 
region  ('cervical  paraplegia'  of  Gull),  from  necrosis  and  projection  of  a 
sequestrum  into  the  canal,  or  rarely  from  the  angular  bending  of  the  spinal 
column.  Paraplegia  occurs  most  frequently  in  cases  of  caries  of  some  part 
above  the  lower  dorsal  spine,  more  rarely  in  lumbar  disease.  The  degree 
of  paralysis  varies  from  mere  weakness  with  parassthesia  to  complete 
paralysis  of  the  lower  limbs,  the  bladder,  and  the  rectum  ;  or  in  rare  cases  the 
paraplegia  maybe  complete  below  the  lower  cervical  region.  There  are  loss 
of  power,  diminished  sensibility,  exaggeration  of  the  reflexes,  more  or  less 
contraction  of  the  limbs,  and,  in  cases  where  the  cervical  or  lumbar  enlarge- 
ment of  the  cord  is  involved,  actual  muscular  degeneration.  Pain  may  or 
may  not  be  present.  For  details  vide  Chapter  on  Nervous  diseases  ; 
Paraplegia,  p.  573. 

Mode  of  Repair. — Repair  in  the  spine  takes  place  just  as  in  other  joints  ; 
the  carious  or  necrotic  process  ceases,  and  the  tissue  injured  beyond  recovery 
is  either  thrown  off  and  comes  away  in  the  discharge,  or  is  encysted  and 
remains  quiescent,  giving  rise  to  no  more  irritation.  The  granulation  tissue 
either  develops  into  fibrous  tissue  or  ossifies,  and  the  adjacent  bone  surfaces 
are  welded  together  ;  in  addition  to  this  bony  splints  and  buttresses  are 
developed  around  the  diseased  spot  and  further  strengthen  it. 

It  is  possible  in  very  early  stages  for  the  inflammation  to  subside,  and 
the  parts  to  return  to  their  original  healthy  condition  ;  but  once  thei'e  is  loss 
of  substance  the  curvature  is  never  lost,  though  the  spine  may  appear 
straighter  from  development  of  compensatory  curves,  or  from  straightening 
out  of  other  mere  transitory  yieldings  due  to  muscular  and  ligamentous 
weakness. 

Treatme7it. — Disease  of  the  spine  requires  treatment  on  exactly  the  same 
principles  as  disease  of  other  joints,  viz.  rest  and  general  hygienic  measures, 
with  such  management  of  abscesses  as  each  case  may  demand. 

The  general  treatment  need  not  be  specified  here  further  than  to  say 
that  nutritious  and  careful  diet,  iron,  and  cod-liver  oil,  together  with  good 
air — sea  air  if  possible — are  the  desiderata.  The  difficulties  arise  in 
obtaining  rest  and  in  the  treatment  of  abscesses.  Rest  implies  absolute 
fixation  of  the  diseased  part :  this  requires  different  arrangements  in  caries 
of  the  upper  and  lower  parts  of  the  spine.  In  cervical  caries  the  best  plan  of 
treatment  is  to  put  the  child  on  a  hard  mattress,  with  a  small  pillow  to  fit 
in  between  the  shoulders  and  occiput  so  as  just  to  support  the  spine  without 
straining  it  :  a  ring  air  or  water  cushion  for  the  head  answers  very  well. 
Sandbags  not  too  tightly  filled  are  then  laid  along  each  side  of  the  neck, 


Treatment  in  Spinal  Caries  J2\ 

packed  well  in,  and  secured  by  one  placed  across  above  the  top  of  the  head, 
a  folded  handkerchief  should  be  carried  across  the  forehead  and  fastened 
to  the  sandbags  at  the  side  to  prevent  any  possible  lifting  of  the  head 
Arrangements  should  be  made  for  defitcation,  &c.,  without  disturbing  the 
child,  by  providing  a  hole  in  the  mattress  or  a  separate  part  in  the  middle 
that  can  be  slid  out.  We  know  no  better  plan  than  this,  as  advised  by  Mr. 
Hilton,  where  it  can  be  carried  out  rigidly,  but  it  is  difficult  to  manage  for  a 
sufficient  time.  Extension  by  means  of  a  head  sling  and  weights  may  be 
applied  in  cases  of  cervical  and  high  dorsal  caries  [vide  Schapps, '  Year  Book 
of  Treatment,'  1895,  p.  276).  As  soon  as  repair  has  fairly  advanced,  as 
e\idenced  by  absence  of  pain  for  some  weeks  previously,  loss  of  tenderness, 
and  diminution  of  thickening,  with  drying  up  of  any  abscesses  that  may  have 
formed,  the  child  should  have  on  a  stiff  leather  or 
poroplastic  collar  moulded  carefully  to  the  neck  and 
occiput,  and  shaped  to  the  shoulders  below  ;  he  may 
then  begin  gently  and  carefully  to  get  about  for  a  short 
time  daily,  but  on  the  least  sign  of  pain  or  swelling  the 
original  plan  must  be  reverted  to. 

Or  a  jurymast  may  be  applied  with  a  plaster  or  felt 
jacket,  either  in  the  original  form  devised  by  Sayre, 
or  of  a  shape  we  prefer  as  less  troublesome,  and  we 
think  more  efficient,  as  shown  in  fig.  168  ;  this  form 
has  the  advantage  of  providing  elastic  support,  of  not 
requiring  to  be  made  of  steel,  and  of  not  tending  to 
press  upon  the  vertex.  The  jurymast  must  be  carefully 
modelled  to  the  particular  case,  and  never  removed, 
but  the  straps  kept  just  taut.  Failing  the  treatment  in 
bed,  the  jurymast  is,  we  think,  as  good  a  plan  as  any, 
though  it  is  troublesome  to  manage,  and  we  seldom  use 
it.  Various  other  methods,  such  as  inflatable  rubber 
collars,  sawdust  collars,  &c.,  are  used  with  advantage 
in  suitable  cases,  i.e.  when  the  disease  is  subsiding. 
Extension  of  the  head  by  weights,  the  trunk  being 
fixed,  is  sometimes  usefully  employed,  but  requires 
care  not  to  overstretch  the  softening  ligaments. 

Caries  in  the  upper  and  mid-dorsal  regions  requires 
as  absolute  recumbency  as  cervical  disease,  but  it  may 
be  either  in  the  prone  or  supine  position,  and  sand- 
bags are  not  required  ;  the  child  should  be  fastened 
down  by  the  simple  plan  shown  in  fig.  162  if  he  can- 
not be  trusted  to  lie  still.  The  jurymast  plan  is 
applicable,  of  course,  to  these  cases  as  well,  and  must  be  used  in  any  case 
where  the  ordinary  jacket  cannot  be  so  applied  as  to  carry  the  weight  of  the 
upper  part  of  the  body. 

The  ordinary  plaster-of-Paris  Sayre's  jacket  is  a  useful  appliance  for  spinal 
caries  in  the  lower  dorsal  and  lumbar  regions.  In  acute  and  rapidly  pro- 
gressing cases  a  period  of  recumbency  should  be  insisted  on,  either  with  or 
without  the  jacket.  Certain  points  are  essential  in  the  use  of  this  appliance. 
I.  Any  sharply  projecting  spines  must  be  protected  by  padding  round  them, 

■S  A 


-A  Juiymast  for 
Cervical  or  Upper  Dorsal 
Caries.  The  altered  shape 
of  the  upright  makes  it 
easier  to  fit,  and  it  is  not 
necessary  to  have  it  of 
steel ;  it  also  prevents  fall- 
ing forward  of  the  head 
without  making  abso- 
lutely vertical  traction. 
The  spring  of  the  steel  is 
replaced  by  elastic  cords 
in  the  straps,  which  have 
been  omitted  from  the 
figure  for  the  sake  of 
clearness. 


722 


Spinal  Disease 


and  by  careful  moulding  of  the  plaster  to  avoid  pressure.  2.  The  jacket 
must  reach  well  up  to  the  root  of  the  neck  in  front  and  behind,  being  shaped 
out  in  the  axillae  ;  this  may  be  done  by  carrying  the  bandages  crosswise  over 
the  shoulders  and  cutting  out   the    cervical   part   afterwards,  or  by  careful 


E" 


&r^ 


Fig.  169. — Patterns  of  Splints  for  Spinal  Caries,  Laminectomy,  &c.  A,  for  fixinghead,  trunk, 
and  lower  limbs ;  B,  for  dorso-lumbar  caries  ;  c,  for  upper  dorsal  ;  _D,  for  dorsal  disease  ;  e,  for 
dorso-lumbar  laminectomy  ;  F,  for  fixing  whole  trunk  and  lower  limbs  in  a  case  of  lumbar  or 
gluteal  abscess,  &c.     These  appliances  are  all  Thomas's  splints  or  modifications  of  them. 

adjustment  of  the  turns  without  crossing  the  shoulders.  3.  The  lower 
border  of  the  jacket  must  come  down  well  over  the  crest  of  the  ilium,  so  as 
to  distribute  the  pressure  and  prevent  the  formation  of  sores  on  the  crest 
and  iliac  spines.     In  fact,  the  jacket  must  be  closely  fitting  and  envelop  the 


Saj're's  Jacket 


723 


^1    i — 


whole  spine  from  neck  to  pelvis,  and  not  be,  as  it  too  often  is,  a  mere  wisp 

round  the  waist.    We  used  generally  to  apply  these  jackets  in  the  out-patients' 

room,  with  the  child  lying  on  its  face  across  two  chairs  with  a  gap  between 

them  ;  the  tripod  may,  of  course,  be  used,  but  with  the  greatest   caution,  to 

prevent   any   stretching,  and   it    must   be   remembered  that    the    point    in 

applying  the  jacket  is  to  fix  the  spine  and  prevent  any  further  pressure,  not 

to  pull  the  surfaces  apart — it  would  be   as 

rational   to  put   on  powerful  extension  and 

counter  extension  after  excision  of  the  knee,  ~^ 

dragging  the  bones  away  from  one  another, 

as  to  try  to  extend  a  carious  spine.     Of  the 

various  modifications  of  the  jacket  we  have 

no  experience.     With  careful  management  a 

jacket  will  last  from  nine  months  to  a  year  if 

the  child  does  not  grow  out  of  it,  but  usually 

hospital  patients  require  new  ones  every  two 

or  three  months.     The  plan  of  putting  on 

two  jerseys  and  changing  the  inner  one  by 

tacking  a  new  one  to  its  lower  edge,  and 

then  drawing  it  upwards  beneath  the  jacket 

by  pulling   the   old   one   over  the   head,  is 

ingenious  and    saves   frec^uent    changing  in 

some  cases.     Pain  after  a  jacket  is  put'  on 

usually  means  pressure  at  some  point,  and 

should  lead  to  careful  examination  :  if  at  the 

hips    or    axilhe,    it    may    be    relieved     by 

judicious  packing  or  cutting  out ;  if  in   the 

back,  the  jacket  must  be  removed,  or  it  will 

cause  sores.    Free  dusting  between  the  jersey 

and  the  sk'in  with  powdered  boric  acid,  or, 

in  dirty  people,  with  pulv.  hyd.  ammon.,  is 

useful.     P'rom    six   to    eight    bandages    are 

usually  required  for  a  jacket  in  a  child  ;  they 

should  be  applied  in  spirals  so  as  to  cross  and 

strengthen  one  another,  and  care  must   be 

taken  not  to  allow  the  edges  to  be  thin  and 

weak.      'Dinner  pads'  are  not  necessary  if 

the  bandages  are  put  on  judiciously  ;  a  soft 

patch  in  the  jacket  over  the  abdomen  does 

not  demand  a  re-application  so  long  as  the 

rest  of  the  jacket  is    firm.     In  some  cases, 

where,  from  the  presence  of  abscesses  in  the 

back,  or  co-existent  hip  disease,  or  flexion  of 

the  legs  from  psoas    abscess,  a  jacket  is   inapplicable,  we  use  a  double 

Thomas's  hip  splint  and  find  it  very  useful ;  it  ensures  recumbency,  keeps 

the  spine  at  rest,  extends  the  legs,  and  does  not  interfere  with  dressings 

nor  require  removal  (figs.  169,  170).     Should  the  child  be  fit  to  be  on  its 

legs,  it  can  get  about,  with  crutches,  in  a  double  Thomas's  splint. 

Poroplastic  and  other  jackets  have  only  doubtful  advantages  over  the 

3  A  2 


Fig.  170.  — Caries  of  the  Spine,  with 
double  ilio-lumbar  abscess,  treated 
by  the  application  of  a  double 
Thomas's  splint. 


724  spinal  Disease 

original  Sayre's,  and  have  many  drawbacks  ;  they  are  rather  appHcable  as 
protections  after  consohdation  has  taken  place  than  as  a  mode  of  treatment 
for  active  disease.  Of  the  various  special  apparatus  we  can  only  speak 
in  the  same  terms,  but  not  from  actual  experience  of  them  :  we  have  never 
been  tempted  to  try  them. 

While  we  have  described  the  management  of  Sayre's  jackets  and  the  jury- 
mast  we  have  personally  almost  entirely  given  up  their  use  in  favour  of  absolute 
recumbency  with  or  without  a  Thomas's  spine  splint.  We  believe  no  treatment 
is  so  good  as  absolute  confinement  to  a  recumbent  posture,  but  it  must  be 
absolute  ;  there  must  be  no  raising  of  the  body  for  washing  or  feeding  or 
emptying  the  bowels.  The  best  plan  is  to  keep  the  child  on  a  blanket- 
covered  board  on  which  he  can  be  carried  to  and  from  bed  and  his  day-room 
or  spinal  carriage.  From  this  board  he  should  never  be  raised,  though  he 
may  be  occasionally  rolled  over  on  to  his  side  to  sponge  the  back. 

If  it  were  possible  to  reach  and  remove  the  source  of  suppuration  in  all 
cases,  the  management  of  spinal  abscess  would  be  that  of  all  other  abscesses 
in  connection  with  bone  disease,  but  the  question  is  not  a  simple  one,  and 
each  case  has  to  be  judged  for  itself.  In  cervical  disease,  as  a  rule,  all 
abscesses  should  be  opened  as  soon  as  they  develop,  for  they  are  apt  to  track 
widely  down  the  neck  or,  pointing  in  the  pharynx,  to  become  septic  or  a  source 
of  danger  from  pressure.  Hence  antiseptic  incision,  by  dissection  at  the  pos- 
terior border  of  the  sterno-mastoid,  is  the  best  treatment.  In  one  case  where 
the  disease  was  of  the  spinous  process  alone,  we  opened  the  abscess,  and  later 
removed  the  necrosed  spine  ;  and  this,  perhaps,  might  sometimes  be  done  in 
necrosis  of  the  bodies  as  proposed  by  Mr.  Treves  more  especially  for  lumbar 
necrosis.  Opening  the  abscess  in  the  pharynx  is  not  a  good  plan,  and  should 
only  be  done  in  an  emergency  where  the  pressure  is  threatening  suffoca- 
tion ;  even  then  we  should  prefer  to  do  tracheotomy  and  then  open  the 
abscess  in  the  neck  at  leisure,  allowing  the  tracheotomy  wound  to  close. 

Abscess  due  to  upper  dorsal  caries  does  not  usually  come  to  the  surface, 
though  no  doubt  it  often  exists  hidden  in  the  posterior  mediastinum  ;  where  if 
it  gives  rise  to  symptoms  it  may  be  recognised,  as  in  the  case  related  on  p.  718. 
Abscess  pointing  in  the  lumbar,  iliac,  or  psoas  area  is  the  condition  most 
commonly  met  with  ;  as  to  its  treatment,  our  opinion  is  that  if  the  abscess  is 
on  the  point  of  bursting,  or  gives  rise  to  much  pain,  or  is  increasing,  it 
should  be  opened  at  once  with  full  antiseptic  precautions — the  opening 
being  made  in  the  loin  if  there  is  any  cavity  there  of  sufficient  size,  or,  if  not, 
in  some  cases  it  is  a  good  plan  to  pass  a  long  probe  from  the  lower  opening, 
iliac,  psoas,  or  gluteal,  as  the  case  may  be,  and  cut  down  upon  it  in  the  loin. 
Where  the  abscess  is  small,  chronic,  and  stationary,  and  where  no  adequate 
ti'eatment  has  been  hitherto  adopted  and  thei'e  is  not  much  pain,  it  is 
justifiable  to  wait.  The  pus  may  be  absorbed,  there  may  be  no  sequestra 
to  keep  up  irritation,  and  the  caries  may  subside  with  rest,  while  we  cannot 
remove  the  disease  if  it  does  not  subside.  When  once  opened  there  is 
always  the  possibility  of  dressings  slipping  and  the  wound  getting  foul,  with 
the  usual  result  of  slowly  progressive  or  acute  septic  poisoning.  But  if  the 
conditions  mentioned  above  exist,  or  if  the  abscess  is  large  or  does  not 
subside  after  a  few  weeks  of  absolute  rest  in  bed,  it  is  better  emptied.  All 
spinal  abscesses,  when  opened,  should  be  dealt  with  by  the  method  already 


spinal  Abscess  725 

mentioned  as  suitable  for  chronic  abscesses  elsewhere — i.e.  they  should  be 
opened  freely,  all  their  contents  thoroughly  wiped  and  washed  out ;  the  wall 
of  the  abscess  being  thoroughly  cleaned,  the  cavity  should  then  be  injected 
with  iodoform  emulsion  and  the  wound  closed.  Should  there  be  subsequent 
evidence  of  sepsis  from  imperfect  management  of  the  wound,  it  must  be 
opened  and  drained,  but  this  must  be  looked  upon  as  a  serious  disaster.  If 
however,  the  wound  heals  without  fever,  but  the  abscess  gradually  refills, 
the  failure  is  due  merely  to  incomplete  removal  of  the  diseased  material, 
and  the  operation  must  be  repeated  as  often  as  fluid  re-collects.  By  this 
method  excellent  results  will  be  obtained  if,  and  this  is  the  whole  question, 
sepsis  is  avoided.  As  to  lumbar  exploration  and  removal  of  sequestra,  the 
plan  introduced  by  Mr.  Treves,  we  confess  we  rather  agree  with  Mr.  Owen 
that,  while  opening  the  abscess  as  near  the  seat  of  disease  as  possible  is  of 
course  good,  it  is  but  rarely  that  we  can  hope  to  make  out  the  exact  condition 
of  parts  or  find  the  sequestra  in  sitii^  and  the  method  is,  as  already  pointed 
out,  only  applicable  to  lumbar  disease.  Nevertheless  the  abscess  should  be 
explored  with  the  finger  in  order  to  ascertain  the  size,  shape,  and  relations 
of  the  cavity,  as  well  as  to  reach,  if  possible,  the  original  seat  of  the  disease, 
and  remove  any  sequestra  and  wash  or  sponge  out  any  caseous  lymph  lying 
loose  in  the  abscess  cavity.  This  is,  of  course,  quite  a  different  matter  from 
cutting  down  upon  vertebral  bodies.  It  is  not  wise  to  scrape  these  abscesses 
or  to  use  any  strong  antiseptic  lotion,  since  anything  more  than  gentle 
wiping  out  is  apt  to  lead  to  bleeding  from  the  wall  of  the  cavity,  and  any 
strong  lotion  may  be  imperfectly  emptied  out  of  the  cavity,  and  so  may  give 
rise  to  poisoning. 

Where  paraplegia  occurs  strict  recumbency  in  bed  is  the  only  treat- 
ment, with  very  careful  general  management  and  the  utmost  watchfulness  to 
avoid  bedsores.  All  discharges  must  be  carefully  cleaned  away  and  the 
parts  kept  .dry  and  powdered  with  boric  acid.  Occasional  washings  with 
strong  spirit  tend  to  harden  tlie  skin  and  prevent  pressure  sores.  Any  con- 
tractures of  the  limbs  should  be  prevented  as  far  as  possible  by  suitable 
appliances.  The  internal  administration. of  large  doses  of  iodide  of  potassium 
is  highly  recommended  by  our  friend  Dr.  Gibney  of  New  York,  but  it  has 
failed  in  our  own  hands.  Mercury  may  be  tried  with  advantage  in  some  cases. 
Counter-irritation  in  the  form  of  blisters  or  the  actual  cautery  is  sometimes 
of  service.  Where  the  paraplegia  resists  all  treatment  for  a  long  time,  the 
question  of  trephining  the  spine  ('  laminectomy ')  and  removing  the  source  of 
pressure  is  to  be  considered.  In  one  case  in  which  we  operated  we  removed 
a  thick  layer  of  lymph  from  within  the  spinal  canal,  and  a  paraplegia  of  six 
months'  standing,  which  had  resisted  all  other  modes  of  treatment,  at  once 
began  to  improve,  but  the  benefit  was  only  temporary.  In  two  of  our  cases 
complete  recovery  of  power  of  walking  followed  the  operation,  but  we  limit 
its  application  to  cases  in  which  paraplegia  has  persisted  after  at  least  six 
months'  absolute  recumbency.  In  cases  where  paraplegia  has  come  on 
rapidly,  and  is  due  to  pressure  of  an  abscess,  the  operation  should  no  doubt 
be  done  earlier  {vide  Thorburn,  '  Brit.  Med.  Jour.,'  June  30,  1894).  Dr. 
Macewen  has  recorded  some  successful  cases  {vide  Address,  '  Brit.  Med. 
Jour.,'  Aug.  II,  1888).  Within  the  last  few  years  a  great  impetus  has  been 
given  to  this  operation,  and  sufficient  success  has  been  obtained  to  fully 


726  spinal  Disease 

justify  it  in  cases  where  paraplegia  does  not  improve  by  long-continued  rest. 
The  cord  may  be  compressed  by  sequestra  or  by  an  extradural  abscess,  or 
possibly  by  distortion  of  the  spine,  but  most  commonly  the  pressure  is  due 
to  effusion  of  thick  tough  lymph  on  the  surface  of  the  theca.  For  details  of 
the  operation  we  must  refer  to  the  special  works  on  operative  surgery.  After 
the  operation  some  such  apparatus  as  that  figured  (fig.  169,  A,  c,  or  e)  should 
be  applied  until  the  parts  have  consolidated.  Our  own  experience  is  that 
the  operation  is  seldom  called  for,  and  that  the  great  majority  of  cases  of 
compression  paraplegia  improve  by  continuous  rest  in  bed. 

Disease  of  the  sacrum,  with  abscess  pointing  into  the  rectum,  is  a  des- 
perate condition.  The  abscess  is  certain  to  be  septic,  and  can  only  be 
reached  through  the  rectum  unless  it  has  burrowed  down  to  the  sciatic 
notch,  or  points  at  the  back,  as  it  may  do.  In  one  case  we  tried  to  remove 
the  disease,  but  in  consequence  of  patency  of  the  theca  below  its  normal 
point  it  was  wounded,  and  the  child  died  of  meningitis  ;  the  post-mortem 
showed  that  any  such  operation  would  have  been  exceedingly  difficult,  and 
probably  impracticable. 

The  prognosis  in  spinal  disease  depends  upon  the  stage  to  which  the 
mischief  has  advanced,  the  presence  of  other  tubercular  lesions,  and  the 
amount  of  care  that  can  be  bestowed  upon  the  case.  It  is  not  necessarily 
bad,  and  under  favourable  circumstances  is  decidedly  good ;  but  from  one 
to  three  years'  treatment  or  even  more  is  required. 

Atlanto-axial  disease  is,  as  already  remarked,  rare  in  children  ;  it  is  essen- 
tially the  same  disease  as  tuberculosis  of  any  other  joint,  but  its  importance 
depends  upon  the  effects  liable  to  follow  softening  of  the  ligaments  and 
sudden  displacement  of  the  odontoid  process,  viz.  sudden  death  from  pressure 
upon  the  upper  cervical  cord.  Occipital  pain,  rigidity  and  thickening  of  the 
neck,  with  perhaps  paresis,  are  the  general  symptoms ;  there  may  be  special 
difficulty  in  rotating  the  head.  The  general  rules  for  cervical  caries  apply 
in  other  respects  to  this  locality. 

Disease  of  the  costo-verteljral  articulations  sometimes  occurs,  either 
alone,  or  as  a  result  of  extension  from  disease  of  the  spine  or  a  rib.  Pain, 
which  may  be  radiating,  and  formation  of  abscess,  are  usually  the  only 
symptoms  by  which  the  disease  can  be  recognised.  The  abscess  may  point 
either  in  the  back  or  lumbar  region  ;  possibly  some  cases  of  psoas  abscess 
depend  upon  this  lesion.  It  is  likely  to  be  mistaken  for  spinal  caries,  but 
the  absence  of  curvature,  the  slight,  if  any,  rigidity,  and  the  unilateral  pain 
and  suppuration,  as  well  as  the  results  of  exploration,  will  probably  enable 
the  difficulty  to  be  cleared  up.  Fixation  in  a  plaster  jacket  with,  if  neces- 
sary, a  window  for  discharge,  or,  better  still,  one  of  the  appliances  figured 
(fig.  169)  is  the  best  treatment  if  the  disease  is  intractable. 


727 


CHAPTER   XXXIII 

CLUB-FOOT,    DEFORMITIES    OF    LIMBS,    ETC. 

The  deformity  known  as  club-foot  or  talipes  may  be  congenital  or  acquired. 
The  varieties  of  the  congenital  affection  are  named  as  follows  : 

Tahpes  varus  -v 

"  .  I  the  simple  forms. 

,,       equmus 

„       calcaneus      j 

Talipes  equino-varus         )     , 

,  1  [■  the  compound  forms. 

„       calcaneo-valgus    J  ^ 

Talipes  cavus  may  be  simple  or  associated  with  equino-varus  or  equinus. 

The  only  common  form  of  club-foot  is  equino-varus  ;  this  deformity  is 
sometimes  called  simply  varus,  but  inasmuch  as  the  distortion  is  a  compound 
one  in  almost  all  cases,  we  shall  consider  it  under  the  more  accurate  title — 
and  this  is  the  more  necessary,  since  its  successful  treatment  largely  depends 
upon  recognition  of  this  complexity.  Calcaneo-valgus  is  the  next  most 
common  form  ;  the  others  are  only  occasionally  met  with,  and  as  great 
rarities  anomalous  forms  such  as  calcaneo-varus  and  equino-valgus  are 
seen. 

The  general  appearance  of  congenital  equino-varus  is  seen  in  the  figures. 
The  heel  is  drawn  up  (equinus)  and  the  anterior  half  of  the  foot  is  adducted 
and  rotated  inwards  upon  an  antero-posterior  axis,  the  adduction  and 
rotation  taking  place  at  the  transverse  tarsal  joint.  Considering  this 
deformity  more  in  detail,  it  will  be  found  that  abnormalities  exist  in  the 
muscles,  ligaments,  bones,  and  fascite  of  the  foot,  and,  though  the  subject 
has  long  been  under  investigation,  we  owe  to  Mr.  Parker  and  Mr.  Shattock 
much  of  our  information  upon  the  share  taken  by  these  several  structures 
in  the  maintenance  of  the  malposition.  We  use  the  word  '  maintenance  '  to 
show  that  we  believe  that  the  deformity  is  due  to  persistent  fixation  of  the 
foot  in  a  distorted  attitude  rather  than  to  any  active  displacement  caused  by 
muscular  or  ligamentous  contraction.  In  describing  the  anatomy  of  tahpes 
we  acknowledge  freely  our  indebtedness  to  Mr.  Parker's  work.^ 

In  talipes  equino-varus  the  posterior  ligament  of  the  ankle  joint,  the 
anterior  part  of  the  internal  lateral  ligament,  and  the  astragalo-scaphoid  and 
inferior  calcaneo-scaphoicl-  ligaments  are  those  which  are  especially  tight.  In 
addition  to  these  the  plantar  ligaments  and  plantar  fascia  help  to  maintain 
the  concavity  of  the  sole  of  the  foot  which  co-exists  with  the  equino-varus. 

1  Congenital  Club-foot,  1887. 

2  Constituting  the  '  astragalo-scaphoid  capsule  '  of  Parker. 


728  Club-foot,  Deformities  of  Limbs,  &c. 

In  severe  cases  the  whole  of  the  hgaments  on  the  inner  side  of  the  foot  are 
shortened,  and  there  may  be  adventitious  fibrous  bands. 

Besides  the  hgamentous  structures,  the  tibiahs  posticus  and  anticus,  as 
well  as  the  flexors  of  the  toes,  the  short  muscles  of  the  sole,  and  the  muscles 
of  the  calf  acting  upon  the  tendo  Achillis,  contribute  to  the  maintenance  of 
the  deformity,  though  it  has  been  shown  that,  with  the  exception  of  the 
tendo  Achillis,  all  the  rest  may  be  divided,  and  yet,  unless  the  ligaments  are 
also  cut,  but  little  effect  can  be  produced  upon  the  malposition.  This  is, 
however,  not  always  the  case,  and  it  is  probable  that  the  share  taken  by  the 
different  factors  in  talipes  is  not  always  the  same.  Mr.  Parker  places  the 
resisting  structures  in  equino-varus  in  early  life  in  the  following  order  of 
importance  : 

(i)  The  astragalo-scaphoid  capsule.  (2)  The  tendo  Achillis.  (3)  The 
skin  of  the  inner  border  of  the  foot.  (4)  The  bony  framework  of  the  foot. 
(5)  The  other  ligaments  and  muscles. 

As  to  the  bones,  the  trochlear  surface  of  the  astragalus  is  increased  poste- 
riorly and  diminished  in  front,  and  the  neck  of  the  astragalus  is  lengthened 
and  directed  more  obliquely  inwards  than  normal  ;  the  articular  surface  on 
the  head  lies  further  inwards  than  usuaL  The  '  calcaneum  lies  in  a  position 
of  exaggerated  rotation  inwards  beneath  the  astragalus,  and  in  one  case  was 
found  fused  with  the  navicular.'  The  lower  ends  of  the  tibia  and  fibula  are 
rotated  inwards.  The  exact  form  of  the  astragalus  appears  to  vary  with  the 
severity  of  the  case. 

The  drawing  up  of  the  os  calcis  tends  to  throw  the  head  of  the  astragalus 
downwards,  and  the  front  of  the  foot  is  inverted  at  the  transverse  tarsal 
joint,  and  so  the  scaphoid  slips  partially  off  the  astragalus  and  comes  to 
articulate  with  the  tibia.  The  cuboid,  cuneiform,  and  metatarsals  are  also 
rotated  inwards,  and  further  retracted  by  the  long  and  short  muscles  so  as 
to  contract  the  sole  of  the  foot,  thus  producing  cavus.  In  some  cases  all 
the  tarsal  bones  show  a  tendency  to  curvature  with  the  concavity  inwards, 
and  the  direction  of  their  articular  surfaces  is  altered.  The  fibula  may  lie 
ientirely  behind  the  tibia,  and  the  tendo  Achillis,  being  brought  close  to  the 
inner  ankle,  may  he  nearer  the  posterior  tibial  artery  than  in  the  normal 
foot.  In  a  case  we  dissected  the  flexor  longus  digitorum  lay  dii-ectly  over 
the  tibialis  posticus.  Bursa;  are  found  over  the  prominences  of  the  foot,  and 
may  exist  even  in  •intra-uterine  life. 

In  early  stages  and  slight  cases  it  appears  that  the  astragalus  is  natural 
in  appearance,  in  more  severe  deformity  it  is  wasted  and  the  neck  deviates  ; 
there  is  not,  however,  any  constant  relation  between  deviation  of  the  neck 
and  deformity.  In  one  or  two  cases  that  we  have  seen  the  deviation  of  the 
foot  inwards  was,  we  thought,  at  the  scapho-cuneiform,  not  at  the  transverse 
tarsal  joint.  The  ordinary  result  of  these  changes  is  adduction  and  rotation 
inwards  of  the  front  half  of  the  foot,  with  elevation  of  the  heel  (figs.  171,  172). 

In  valg'us  the  whole  foot  is  everted  at  the  ankle  or  the  subastragaloid 
joint,  as  well  as  rotated  outwards  at  the  transverse  tarsal  joint ;  ^  and,  further, 
the  sole  is  flattened,  or  in  infants  oftener  convex  downwards,  the  tibialis 
posticus  and  calcaneo-scaphoid  ligaments  being  stretched  and  the  peronei 
shortened. 

1  So  that  valgus  is  not  the  exact  opposite  of  varus. 


Talipes  Equino-vartis 


729 


In  equlnus  the  tendo  Achillis  and  posterior  ligament  of  the  ankle  joint 
are  shortened  and  the  astragalus  is  drawn  back,  so  that  only  the  front  of  the 
trochlea  is  between  the  malleoli  ;  there  are  other  less  important  displace- 
ments of  other  tendons.'  Talipes  equinus  is  said  to  be  an  exceedingly 
rare  condition  as  a  congenital  deformity  ;  we  have  seen  a  very  pure  example 
in  which  intra-uterine  pressure  marks  upon  the  knees  and  shoulders  were 
very  obvious.  In  calcaneus  the  chief  contracted  structures  are  the  ex- 
tensors of  the  great  and  lesser  toes,  the  tibialis  anticus,  and  the  anterior 
ligament  of  the  ankle  joint  ;  thus  the  foot  is  flexed  upon  the  leg  and  the  patient 
walks  upon  the  heel  ;  the  front  of  the  foot  may  be  much  atrophied.  The 
trochlear  surface  of  the  astragalus  is  prolonged  forwards  as  far  as  the  navicular 
facet,    and  the  inner  malleolar  surface  is  prolonged  forwards  (Parker  and 


Fig.  171. 


-Severe  Talipes  Equino- 
Varus. 


-Ver>-  severe  Talipes  Equino- 
Varus. 


Shattock).  We  have  noticed  extreme  projection  backwards  of  the  os  calcis 
in  congenital  calcaneus,  as  if  the  foot  were  partially  dislocated  backwards  at 
the  ankle,  a  deep  depression  existing  over  the  front  of  the  joint.  Hollow 
club-foot  (cavus)  depends  upon  shortening  of  the  muscles  of  the  sole  of  the 
foot  and  the  plantar  ligaments,  as  well  as  the  flexors  of  the  toes,  the  tendo 
Achillis,  and  tibialis  posticus.  By  the  arching  of  the  foot  and  the  drawing 
up  of  the  heel  the  extensors  of  the  toes  are  put  upon  the  stretch,  and  hence 
the  toes  are  drawn  up  in  hyper-extension,  so  that  the  deformity  known  as 
'  hollow  claw-foot '  is  usually  produced. 

The    compound  forms    of  talipes  need  no  special  description,   as  they 
consist  of  combinations  of  the  simple  varieties.- 

1    Vide  Mr.  Parker's  book. 

-  Holmes  Coote,  in  St.  Earth's  Reports,  vol.   ii.   1866,  describes  a  form  of  talipes 
consisting  in  rigidity  of  the  tendo  Achillis  with  subsequent  development  of  flat-foot,  of 


730  Chib-foot,  Deformities  of  Limbs,  &c. 

Etiology. — Many  theories  have  been  proposed  to  account  for  the  occur- 
rence of  club-foot,  and  it  is  possible  that  most  of  them  are  true  in  certain 
cases  ;  we  do  not  think  any  one  cause  alone  will  explain  all  cases  of  club- 
foot, though  the  great  majority  are  due  to  malposition  /;?  utero. 

Little  considered  talipes  due  to '  a  morbidly  excitable,  retractile  disposition ' 
of  muscles,  comparable  to  the  reflex  torticollis  of  later  life. 

Central  and  peripheral  nerve  lesions,  causing  spasm  or  paralysis  of 
muscles,  may  account  for  some  cases,  where,  for  instance,  spina  bifida  or 
absence  of  brain  (anencephale)  is  associated  with  talipes  ;  on  the  other 
hand,  Parker  and  Shattock  found  both  cord  and  nerves  perfect  in  a  case 
they  examined.  In  oiDposition  to  them,  however,  we  must  point  out  that  the 
nutrition  of  the  talipedic  limbs  is  often  impaired,  and  they  are  fat,  flabby, 
and  toneless  ; '  the  muscles  may,  however,  react  normally  to  electricity. 
Intra-uterine  pressure  associated  with  deficient  amniotic  fluid  (Cruveilhier)is 
no  doubt  the  cause  in  some  children.  We  have  found  talipes  associated 
with  intra-uterine  constrictions  and  amputations  from  amniotic  bands,-  and 
in  another  case,  alluded  to  above,  the  deformity  co-existed  with  pressure 
marks  ;  but  the  distortion  is  also  found  where  the  liquor  amnii  is  abundant, 
and  such  explanation  hardly  accounts  for  single  talipes  as  the  only  mal- 
formation. 

A  persistence  of  the  natural  early  fcetal  position  (Eschricht)  explains 
some  cases  (of  equino-varus  and,  later,  calcaneus)  ;  in  others,  again,  deficient 
development  of  parts  in  the  cause,  as  in  cases  where  congenital  absence  of 
the  fibula  has  produced  valgus,  and  this  may  be  compared  with  fig.  i86,  of 
absence  of  the  radius  producing  club-hand.^  Hueter  supposed  that  obliquity 
of  the  neck  of  the  astragalus  was  a  cause,  but,  as  shown  by  Parker,  this  may 
occur  without  talipes,  and  talipes  may  exist  without  it.  Intra-uterine  joint 
disease  possibly  explains  some  cases,  and  adhesions  are  found  in  certain 
instances  in  the  joints.  Cruveilhier,  Forster,*  Parker  and  Shattock,  and 
Silcock  have  pointed  out  that  where  the  limbs  are  interlocked  in  abnormal 
positions  they  will  exert  pressure  on  each  side  quite  independently  of  the 
amount  of  fluid  ;  we  have  frequently  seen  cases  where  clearly  the  feet  had 
interlocked  :  the  one  foot,  being  in  a  position  of  extreme  calcaneo-valgus, 
was  received  into  the  concavity  of  the  other,  which  had  severe  equino-varus.-^ 
For  further  discussion  of  the  subject  we  must  refer  to  the  admirable  works, 
so  often  quoted,  of  Messrs.  Parker  and  Shattock,  and,  in  acknowledging  our 
indebtedness  to  them,  we  can  confirm  many  of  their  observations  by  our 
own  ;  we  think  that  nearly,  but  not  quite,  all  of  the  cases  can  be  explained 
mechanically  by  pressure  or  position  in  utej'o,  bad  packing  as  it  v/ere,  and 

which  it  appears  to  be  an  early  stage  ;  he  calls  it  '  rectangular  talipes  equinus,'  the  foot 
keing  kept  at  a  right  angle  with  the  leg. 

1  Possibly  this  may  be  explained  by  the  absence  of  natural  exercise  in  utero,  when  the 
feet  are  interlocked  or  misplaced. 

2  Parlier  and  Shattock  also  mention  a  case  of  theirs. 

5  Club-hand  is,  however,  probably  the  result  of  pressure  causing  arrest  of  development 
of  the  prse-axial  border  of  the  limb. 

4  Missbildtingcn  des  Menschen,  Taf.  xxvi.  fig.  i.,  from  Cruveilhier;  the  figure  is  copied 
in  Bodenhamer,  as  the  subject  had  also  imperforate  anus. 

'"  Confirmation  of  this  view  of  the  causation  of  talipes  is  found  in  the  other  deformities 
similarly  produced,  such  as  '  genu  recurvatum,  &c.'     Vide  figs.  i88,  189. 


Etiology  of  Club-foot 


731 


so-called  'club-hand'  is,  we  believe,  due  to  the  same  cause.  One  of  the 
strongest  proofs,  to  our  mind,  is  the  tendency  seen  in  children  to  assume, 
long  after  birth,  the  position  they  occupy  in  utcro,  with  the  feet  or  hands 
locked  in  the  talipedal  attitude  (fig.  173).  The  result  of  habitual  positions  in 
producing  curved  bones  in  rickety  children  is  interesting  also  in  this  relation 
\vide  fig.  40). 

It  is  sometimes  said  that  talipes  is  merely  an  arrest  of  development,  a 
'failure  to  unwind'  the  foot  from  its  earlier  or  later  fcetal  position  :  we 
think  this  hardly  fully  expresses  the  truth,  there  is  something  more  ;  an 
actual  pressure  and  sc^ueezing  together  of  the  parts  in  an  abnormal  position 
is  certainly  what  has  occurred — in  most  of  the  more  severe  cases  at  any  rate. 

As  to  the  degree  of  deformity,  we  cannot  do  better  than  quote  Mr. 
Parker's  words  :  'When  the  cause  begins  to  act  very  early  in, and  continues 
throughout,  intra-uterine  life,  the  deformity  will  be  a  very  fundamental  one  ; 
whereas,  if  the  cause  begins  to  act  at  a  later  period,  or  if  it  be  continued  for 
a  short  time  only,  the  re- 
sulting deformity  will  be 
less  severe.' — '  Brit.  Med. 
Jour.,'  October  27,  1888. 

The  treatment  of  all 
cases  of  club-foot  in  chil- 
dren can  be  successfully 
carried  out  without  any  but 
the  most  simple  apparatus, 
except  in  the  instances 
where,  from  neglect,  old 
cases  may  require  tarsec- 
tomy  ;  we  shall,  therefore, 
confine  ourselves  to  de- 
scription of  the  methods 
we  have  found  most  useful, 
and   omit   all  reference  to 

costly  and  complicated  appliances.  The  general  principles  of  management 
are  the  same  for  the  different  forms  of  club-foot,  so  that  we  may  take  an 
ordinary  case  of  equino-varus  as  a  type.  Several  questions  have  to  be 
considered,  such  as  (i)  When  is  treatment  to  be  begun  ?  (2)  Is  a  cutting 
operation  to  be  performed  ;  if  so,  what  structures  should  be  divided,  and  at 
what  age  ?  (3)  When  operation  is  required  should  all  the  tense  structures 
be  divided  at  the  same  time,  and  should  reduction  of  the  deformity  follow 
immediately  on  the  operation  or  be  delayed?  (4)  What  is  the  best  apparatus 
to  apply?     (5)  How  long  is  treatment  to  be  continued. 

(i)  It  might  be  thought  unnecessary  to  insist  upon  the  treatment  of  club- 
foot being  begun  immediately  after  birth,  but  we  have  more  than  once  had 
cases,  several  months  or  more  old,  brought  for  relief,  in  which  not  only  had 
nothing  been  attempted,  but  the  friends  had  been  told  the  child  was  not  old 
enough  for  any  treatment  yet.  Of  course  with  a  child  a  few  days  old  more 
can  be  done  in  a  week  than  is  possible  in  a  month  with  an  older  child.  Treat- 
ment should  be  begun  without  a  day's  delay.  (2)  The  question  of  tenotomy 
has  been  allowed  to  become  largely  one   of  fashion,  some  surgeons  advising 


Fig.  173- 


-Showing  how  Talipes  is  produced  by  '  bad  pack- 
.'     (From  a  photograph  by  Mr.  C.  S.  Ashe.) 


732  Club-foot,  Deformities  of  Limbs,  &c. 

it  in  nearl}^  every  case,  and  others  insisting  not  only  on  its  needlessness, 
but  upon  the  harm  resulting  from  it.  The  rules  we  follow  on  this  point  are  : 
If  the  child  is  seen  within  the  first  few  weeks  of  life,  operation  is  very  rarely, 
if  ever,  necessary.  During  the  next  two  or  three  years  two  points  have  to  be 
considered  :  first,  what  amount  of  care  can  be  expended  upon  the  case  ;  and 
secondly,  how  rigid  are  the  resisting  structures,  i.e.  can  the  deformity  be 
reduced  by  moderate  force  ?  If  the  child  can  be  thoroughly  well  looked  after, 
and  its  splints  applied  regularly  and  intelligently,  operation  is  not  neces- 
sary in  most  cases  under  two  years  old,  although  it  undoubtedly  shortens 
the  time  required  for  reduction,  and  is  sometimes  desirable — certainly  so 
where  there  is  much  rigidity,  and  any  doubt  about  the  efficiency  of  the  care 
and  management.  Where  the  j-igidity  is  so  great  in  a  child  over  three 
months  old  or  thereabouts  that  the  deformity  cannot  be  completely  reduced 
by  reasonable  force,  operation  should  at  once  be  performed  ;  such  cases  are, 
however,  comparatively  rare.  We  see  no  advantage  in  forcible  '  redresse- 
ment '  over  a  cutting  operation.  (3)  In  equino-varus  if  all  the  resisting 
structures  are  to  be  divided,  those  which  maintain  the  varus  part  of  the 
deformity  as  opposed  to  the  equinus  may  be  cut  at  the  same  time,  and  before 
there  is  any  attempt  to  remedy  the  equinus^  or  both  may  be  done  at  the  one 
sitting.  The  plantar  fascia  rarely  requires  division  except  in  neglected  cases. 
Authorities  differ  as  to  the  risks  of  immediate  reduction  after  tenotomy.  We 
do  not  think  the  matter  is  one  of  great  importance,  and  generally  settle 
the  question  by  the  interval  that  is  to  elapse  before  the  next  visit  ;  if  more 
than  two  days,  we  usually  correct  the  defonnity  at  once.  (4)  As  to  the 
question  of  apparatus,  we  may  say  at  once  that  we  have  never  used,  or  seen 
the  advantage  of,  the  more  complicated  instruments — shoes  modified  in 
various  ways  from  Scarpa's,  taliverts,  and  so  on  ;  they  are  too  expensive  for 
the  hospital  class,  and  in  all  classes  we  are  quite  satisfied  with  the  results  to 
be  obtained  by  much  more  simple  means. 

Practically  we  find  one  of  three  appliances  will  meet  almost  every  case  ; 
two  are  of  Dr.  Little's  invention,  and  the  third  is  a  slight  modification  of 
Barwell's  artificial  muscle  plan.  To  take  a  case  of  equino-vai"us  in  which 
the  varus  is  to  be  remedied  first.  The  first  appHance  is  adapted  only  to 
infants  or  children  a  few  months  old.  It  is  simply  a  strip  of  thick  block- 
tin  long  enough  to  reach  from  the  knee  to  just  beyond  the  end  of  the  toes 
when  the  foot  is  pointed  (fig.  174).  This  is  bent  to  fit  the  foot  along  its 
outer  side  in  its  full  equino-varus  position.  It  is  then  bandaged  on,  no 
attempt  being  made  to  remedy  the  equinus  or  varus  ;  when  it  is  securely 
fixed  to  the  leg  and  foot,  the  front  of  the  foot  (i.e.  the  part  beyond  the  trans- 
verse tarsal  joint),  together  with  the  tin,  is  gently  bent  outwards  so  as  to 
slightly  improve  the  varus,  leaving  the  equinus  unaltered.  The  foot  is  left 
in  this  position  till  the  next  day,  or  longer  if  absolutely  necessary,  when  the 
bandage  is  re-applied  and  a  little  further  correction  employed,  and  so  on  till 
the  varus  is  somewhat  over-reduced.  The  equinus  is  then  dealt  with  in  the 
same  way,  the  splint  being  applied  to  the  back  of  the  Hmb.  The  second 
appliance  (fig.  176)  is  simply  Dr.  Little's  tin  splint.  It  may  be  used  with  the 
foot-piece  fixed  at  a  right  angle  with  the  leg-piece,  or  better  movable,  so  as 
to  remedy  the  varus  alone  first.  This  splint  is  applicable  to  older  and  more 
rigid  cases,  as  it  is  a  much  more  powerful  appliance  than  the  last.     It  is 


Appliances  for  Club-foot  y^-ij 

useful  sometimes  to  have  a  slit  cut  in  the  metal  at  the  anj^le  between  the 
leg  and  foot  pieces  running  a  little  distance  along  the  edge  of  the  sole  ; 
through  this  slit  the  bandage  is  carried,  and  so  the  heel  is  more  securely 
fixed  down.  The  third  apparatus  is  Barwell's  artificial  muscle,  applied 
somewhat  simply.  We  use  it  in  two  different  forms.  The  first  form  consists 
of  Mr.  Barwell's  strip  of  tinned  iron  strapped  to  the  front  of  the  leg  ;  on  it  is 
soldered  a  hook.  A  strip  of  strapping,  or  webbing,  or  felt  is  carried  round  the 
front  of  the  foot,  and  to  its  free  end  is  fixed  a  loop  of  stout  indiarubber  cord 
or  drainage  tubing  ;  this  is  then  stretched  up  to  the  hook  above,  so  as  to 
correct  the  deformity.  The  second  way  of  applying  the  muscle  is  that 
shown  in  fig.  175.  The  object  of  using  the  straps  instead  of  the  tin 
splint  and  plaster  is  to  allow  the  apparatus  to  be  taken  off  in  order  to  rub 
and  wash  the  leg,  friction  being  a  point  to  which  we  attach  considerable 
importance,  as  tending  to  prevent,  or  at  least  remedy,  the  great  muscular 
wasting  which  occurs  in  the  course  of  the  treatment  of  talipes  if  any  rigid 


Fig.  174. — Little's  plain 
Tin  Splint. 


Fig.  176.— Little's  Tin 
Talipes  Shoe,  which 
may  have  a  joint  at 
the  junction  of  the 
sole  and  leg  pieces. 


Fig. '175. —The  Artificial  Muscle  Appliance  shown  correcting  the  deformity  in 
a  case  of  Congenital  Equino-varus  (from  a  photograph),  a,  the  rubber  strap 
or  'muscle  ;'  n,  strapping  round  the  foot  ;  c,  the  side  straps  connecting  the 
upper  and  lower  straps.  The  apparatus  is  a  modification  of  Barwell's  original 
plan.     It  is  better  to  have  the  straps  made  to  lace  up  than  to  buckle. 

appliance  is  kept  on  constantly.  The  plan  we  adopt  usually  is  to  use  one  or 
other  of  the  tin  splints,  generally  the  first,  until  the  deformity  is  so  far 
corrected  that  the  muscle  can  be  efficiently  applied  ;  the  latter  is  then  worn 
till  the  cure  is  complete. 

As  to  the  duration  of  treatment  no  hard-and-fast  rule  can  be  laid  down  ; 
it  varies  in  each  case  with  the  rigidity  of  the  parts,  the  age  of  the  patient, 
and  the  care  e.xpended  upon  it.  In  one  case  a  few  weeks,  in  another  many 
months,  may  be  required  before  the  artificial  muscle  stage  is  reached.  As 
soon  as  this  can  be  profitably  applied  the  drudgery  of  the  task  is  over,  but 
the  case  cannot  be  considered  cured  ;  hence  the  answer  to  the  fifth  point, 
that  of  the  duration  of  treatment,  can  only  be  general.  As  Dr.  Little  points 
out,  no  case  is  safe  from  relapse  until  the  patient  is  old  enough  to  watch  him- 
self and  correct  the  earliest  sign  of  return  of  the  deformity,  although  by  the 
use  of  the  artificial  muscle  another  dictum  of  his,  that  there  must  be  no 
walking  till  the  deformity  is  remedied,  may  be  set  aside.     Great  care    is 


734  Club-foot,  Deformities  of  Limbs,  &c. 

required,  in  applying  the  splints,  not  to  be  deceived  by  the  rotation  of  the 
limb,  and  until  the  artificial  muscle  can  be  applied  so  as  to  slightly  over- 
correct  the  deformity  no  walking  is  to  be  allowed  ;  after  this  point  is  reached 
it  does  no  harm,  but  rather  good.  The  essence  of  the  matter  is  largely  in 
the  amount  of  trouble  taken  with  each  case  by  the  surgeon  and  the  friends. 
Some  other  points  in  management  must  be  also  considered.  Manipula- 
tion, i.e.  firmly  holding  the  foot  in  a  slightly  over-corrected  position,  is 
exceedingly  useful,  and  should  be  daily  employed  each  time  the  splints  are 
removed — or  if,  unfortunately,  from  pressure  sores  or  other  causes,  the 
apparatus  has  to  be  left  off,  frequent  inanipulation  prevents  time  from  being 
lost.  The  leg  should  be  firmly  grasped  in  one  hand,  in  such  position  that 
the  patella  looks  directly  forwards,  and  then  the  other  hand  should  be  used 
to  steadily  turn  the  foot  into  position,  bearing  in  mind,  in  each  case,  the  seat 
of  the  deformity  ;  thus  in  varus  the  ankle  joint  must  be  steadied  and  the 
rotation  made  at  the  tranverse  tarsal  joint. 

Pressure  sores  are  to  be  avoided  by  regular  daily  renewal  of  apparatus, 
and  avoidance  of  rucking  up  of  plaster  or  bandages  ;  though,  perhaps, 
strapping  is  more  apt  to  cause  sores  than  webbing,^  it  is  easier  to  keep  on 
in  the  early  stages  of  treatment  ;  we,  however,  generally  use  thin  saddler's 
felt  or  webbing  for  the  foot-strap,  and  carry  it  round  the  ankle  and  foot  in  the 
fashion  shown  in  fig.  177,  but  reversed. 

Should  it  be  decided  that  tenotomy  is  required  in  a  given  case,  the  rules 
for  its  performance  are  as  follows.  To  divide  the  tibialis  posticus  the  limb 
is  laid  upon  its  outer  side  upon  a  firm  pillow,  the  posterior  border  of  the 
tibia  is  felt  for,  and  the  tenotome  passed  in  two  fingers'  breadths  (in  an  infant) 
above  the  inner  malleolus,  in  such  position  that  its  point  justs  hits  the  edge 
of  the  bone  ;  the  knife  is  then  slipped  close  to  the  bone,  between  it  and  the 
tendon,  and  its  edge  turned  towards  the  tendon  ;  the  foot  is  then  held  so  as 
to  correct  the  deformity,  and  by  a  gentle  levering  motion  the  tendon  is 
divided,  cutting  towards  the  skin  ;  as  soon  as  the  tendon  is  felt  to  snap,  the 
knife  is  withdrawn  and  a  collodion  pad  and  bandage  applied.  Occasion- 
ally bleeding  is  free,  but  readily  stops  on  pressure,  and  no  bad  result 
follows.  If  the  edge  of  the  tibia  cannot  be  felt,  a  point  midway  between  the 
front  and  back  of  the  limb  marks  its  position.  The  better  plan  is  to  divide 
the  tibialis  posticus,  together  with  the  ligaments,  through  one  puncture 
opposite  the  transverse  tarsal  joint  in  the  posterior  crease  of  the  sole. 

The  tibialis  anticus  is  best  divided  upon  the  dorsum  of  the  foot,  just  before 
its  insertion  into  the  inner  cuneiform  ;  it  is  easily  felt,  and  the  knife  passed 
beneath  it,  and  division  effected  as  in  the  posterior  tendon. 

The  tendo  Achillis  is  perhaps  the  simplest  of  all.  It  should  be  cut 
about  f  inch  above  its  insertion,  at  its  narrowest  part,  the  knife  being  passed 
well  beneath  it  (i.e.  nearer  the  tibia),  from  the  inner  side  while  the  limb  lies 
on  its  anterior  surface.  Personally  we  prefer  to  pass  in  the  knife  while  the 
tendons  are  held  tense  and  can  be  plainly  felt ;  others  prefer  to  tighten  only 
after  the  tenotome  is  beneath  the  muscle. 

We  are  much  in  favour,  in  suitable  cases,  of  Mr.  Parker's  plan  of  dividing 
all  rigid  structures  at  the  transverse  tarsal  joint,  and  not  limiting  the  section 
to  the  tendons  or  fascia.     The  tubercle  of  the  scaphoid  should  be  felt  for 
1   Vide  Golding  Bird,  Gtiy's  Hospital  Reports,  1882. 


Treatment  of  Talipes  735 

and  the  knife  passed  in  at  the  inner  border  of  the  foot,  just  behind  the  bone  ; 
the  edge  is  then  turned  towards  the  joint  and  made  to  cut  well  into  it, 
dividing  everything  until  the  foot  readily  yields  ;  by  thus  severing  the 
ligaments  subsequent  reduction  is  rendered  much  easier.  Where  this  plan 
is  adopted,  the  tibialis  posticus  and  anticus  are  divided  at  the  same  time  as  the 
rest  of  the  rigid  structures  ;  the  internal  plantar  artery  is  necessarily  cut,  and  we 
have  once  seen  a  traumatic  aneurism  result,  but  no  serious  ill  effect  need  be 
feared,  even  if  bleeding  is  free  at  the  time.^  The  anterior  and  posterior 
ligaments  of  the  ankle  joint  require  division  in  some  cases  of  calcaneus 
and  equinus  respectively. 

It  should  be  remembered  that  in  second  tenotomies  the  characteristic 
snap  is  often  not  felt. 

We  are  not  satisfied  with  the  results  of  fixing  feet  in  plaster  of  Paris, 
either  with  or  without  tenotomy,  but  much  prefer  an  arrangement  where  the 
pressure  may  be  altered  frequently. 

Where  the  artificial  muscle  plan  is  being  employed,  if  tenotomy  is  re- 
quired at  all,  it  is  usually  the  tendo  Achillis  that  needs  division,  since  the 
plaster  is  apt  to  slip  up  towards  the  heel  in  such  cases.  Where  the  other 
splints  are  used,  it  is  better,  if  the  varus  is  corrected  first,  to  divide  the 
tibial  tendons,  &c.,  three  or  four  weeks  before  the  tendo  Achillis  ;  some 
surgeons  prefer  always  to  divide  the  Achilles  tendon  first.  The  peronei  rarely 
require  division  (we  have  never  seen  a  case  suitable  for  peroneal  tenotomy)  ; 
if  they  do,  the  section  is  made  two  fingers'  breadth  above  the  outer  malleolus. 
The  extensor  longus  digitorum  and  proprius  hallucis  may  be  divided  just  below 
the  annular  ligament,  but  we  have  never  found  the  operation  necessary. 

Congenital  valgus  is  best  treated  by  a  muscle  applied  so  as  to  exert 
pressure  in  the  opposite  way  to  varus  ;  it  is,  however,  not  so  readily  corrected. 
The  rare  equinus  requires  muscles  on  both  sides  to  draw  up  the  toes,  usually 
after  tenotomy.  Calcaneus  is  best  treated  by  the  tin  strip  (fig.  174)  or  the 
jointed  form  of  the  splint  (fig.  176). 

Talipes  cavus  is  often  remedied  by  division  of  the  tendo  Achillis  only  ; 
in  other  instances  the  resisting  structures  in  the  sole  may  require  section. 
Where  there  is  much  cavus  with  equinus  it  is  sometimes  necessary  to  attach 
the  '  muscle '  to  a  thin  metal  plate  moulded  to  the  balls  of  the  toes,  to  prevent 
the  foot  strap  from  slipping  into  the  hollow  of  the  sole. 

There  is  no  doubt  that  tenotomy  alone  is  in  many  cases  inadequate,  and 
has  been,  with  the  exception  of  division  of  the  tendo  Achillis,  largely  given  up 
in  favour  of  the  more  complete  and  scientific  operation  of  '  syndesmotomy' 
(division  of  ligaments)  described  by  Parker.  Of  '  open  division '  of  all  the 
resisting  structures,  including  the  skin,  we  have  little  experience  ;  we  have, 
however,  had  one  or  two  cases  in  which  after  '  syndesmotomy '  at  the  trans- 
verse tarsal  joint  the  skin  has  given  way  under  the  strain  of  forcible  reduction 
of  the  deformity.  The  only  harm  resulting  has  been  delay  in  the  healing  of 
the  wound  and  some  little  increase  in  difficulty  in  the  application  of  the 
'  muscle.'     The  principle  of  the  plan  does  not  commend  itself  to  us. 

Excision  of  one  or  more  bones  of  the  tarsus  for  inveterate  club-foot,  as 
employed  by  Davies  CoUey,  Davy,  Lund,  and  others,  is  an  operation  to  be 

'^  Other  cases  of  aneurism  following  division  of  the  plantar  fascia  are  on  record — vide 
Walsham,  Lancet,  January  28,  1888. 


736  Club-foot,  Deformities  of  Limbs,  &€. 

reserved  for  severe  cases  in  older  children,  and  only  employed  when  there  is 
no  hope  of  remedying  the  deformity  by  other  means. 

The  operation  we  prefer  consists  in  making  a  X-shaped  or  oval  incision  on  the  outer  side 
of  the  foot,  the  horizontal  limb  running  along  the  outer  border,  and  the  vertical  part  passing 
across  the  centre  of  the  cuboid.  The  flaps  are  reflected,  the  bones  exposed,  the  tendons 
being  drawn  aside,  and  a  wedge  of  bone  is  removed  entire  or  piecemeal  from  the  outer 
side  of  the  foot ;  a  chisel  is  the  most  convenient  instrument  for  the  purpose.  Various  lines 
of  section  are  employed,  but  the  general  rule  is  to  remove  the  cuboid  always,  and  as  much 
of  the  adjacent  bones  as  the  individual  case  may  require  ;  the  cuneiforms,  head  of  the 
astragalus,  bases  of  the  metatarsal  bones,  and  front  of  the  os  calcis  ma)'  all  require  to  be 
taken  away.i  After  the  operation  the  foot  should  come  readily  into  position  ;  all  bleeding 
having  been  stopped,  and  the  dressings  applied,  the  limb  is  at  first  fixed  lightly  on  a  back 
splint.  The  wound  often  heals  somewhat  slowly,  and  until  it  is  superficial  we  prefer  not 
to  use  forcible  corrective  apparatus  ;  usually  in  about  a  fortnight  the  muscle  may  be  applied. 
It  is  a  good  plan  to  take  away  an  oval  piece  of  the  thick  callous  skin  and  the  under- 
lying bursa  from  the  dorsum  of  the  foot.  We  look  upon  the  operation  as  a  very  valuable 
one  in  suitable  cases — -for  instance,  where  the  patient  walks  upon  the  dorsum  of  the  foot 
and  pressure  sores  are  prone  to  develop,  while  all  the  structures  are  rigid  [vide  fig.  172). 

Excision  of  the  astragalus  alone,  we  think,  is  best  adapted  for  paralytic  cases — in  such 
instances  we  have  removed  the  bone  with  excellent  results  ;  it  may  be  done  without  division 
of  any  important  structure,  by  an  incision  over  the  ankle  joint,  carried  from  the  tibialis 
posticus  to  the  tibialis  anticus,  and  another  one  at  right  angles  to  this,  along  the  inner 
border  of  the  latter  tendon.  By  a  little  careful  dissection  the  bone  can  be  got  out,  the 
only  difficulty  being  with  the  interosseous  ligament.  After  the  operation  a  shapely  foot 
with  a  good  arch  still  remains.     Other  incisions  may  be  used. 

The  most  common  forms  of  paralytic  (acquired)  Talipes  are  equino- 
varus  and  valgus  ;  these,  so  far  as  the  deformity  goes,  are  usually  readily 
treated  by  the  artificial  muscle  method,  and  the  effect  is  generally  immediate 
and  to  a  certain  extent  satisfactory  ;  it  does  not,  of  course,  remove  the  weak- 
ness and  flabbiness  of  the  foot,  but  it  prevents  actual  turning  outwards  or  in- 
wards, and  makes  walking  much  steadier  and  more  sightly.  In  some  few  cases 
light  steel  supports  are  of  value.  Where,  however,  from  long  neglect  the 
deformity  is  irremediable  by  these  means,  the  method  of  excising  the  astragalus 
already  described  may  be  required.  In  very  severe  cases  of  infantile  paralysis, 
where  the  foot  is  perfectly  powerless,  and  especially  where  the  paralysis  ex- 
tends above  the  knee,  and  the  knee  joint  is  flexed,  the  limb  being  flail-like, 
short,  and  useless,  amputation  may  be  required;  this,  however,  should  never 
be  done  in  childhood,  since  there  is  a  possibility  of  improvement.  The 
attempt  to  convert  the  flail-like  distorted  limb  into  a  stiff  stable  support  by 
resection  of  the  knee  and  ankle  joints  ('  arthrodesis ')  has  been  tried,  with  satis- 
factory results,  in  some  cases  ;  in  a  case  we  operated  on  in  1884,  there  was 

1  The  principal  modes  of  tarsectomy  are  : 

1.  Excision  of  a  wedge  of  bone,  irrespective  of  joint  lines  (Davies  CoUe)'). 

2.  ,,  ,,  cuboid  (Little). 

3.  ,,  ,,  astragalus  (Lund)  (chiefly,  we  think,  applicable  to  acquired  talipes). 

4.  ,,  ,,  astragalus,  cuboid  and  scaphoid  (West). 

5.  ,,  ,,  wedge  from  the  neck  of  the  astragalus  (Hueter). 

6.  Linear  osteotomy  of  the  tarsus  or  of  the  leg  above  the  ankle  joint  (Hahn). 

7.  Excision  of  a  wedge  from  the  transverse  tarsal  joint,  &c.  (Rydygier) :  vide  Rydy- 
gier,  Berlin.  Klin.  Woch.  February  5,  1883  ;  also  Lorenz,  Wiener  Klinik,  1884,  H.  5 
and  6  ;  also  Goldschmidt,  Rev.  Mens,  des  Maladies  de  rEnfance,  from  Ccntralbl.  f.  Chir. 
No.  17,  April  1884, 


Acquired   Talipes 


737 


very  considerable  improvement — this  was,  we  believe,  the  first  case  operated 
upon  in  this  country.  Further  experience  has  proved  to  us  the  great  value 
of  this  operation  in  suitable  cases.  Walsham  '  has  practised  shortening  the 
tendons  by  excision  of  a  part  and  suture  of  the  divided  ends,  thus  correcting 
the  deformity  and  allowing  the  lax  muscles  to  act  ;  we  have  also  tried  the 
plan,  with  fair  results  in  two  or  three  cases.  It  is  sometimes  of  much  value. 
Goldthwait  and  others  have  employed  the  method  of  attaching  healthy 
muscles  to  the  tendons  of  paralysed  ones  so  as  to  restore  the  lost  power  of 
the  limb,  a  process  of  muscle  grafting  or  myoplasty.  Good  results  have 
followed  in  some  cases.  We  have  tried  it,  but  our  experience  of  the  operation 
is  not  sufficient  to  justify 
an  opinion  as  to  its  value. 

These  paralytic  limbs 
are,  of  course, .  prone  to 
become  the  seat  of  chil- 
blains and  ulcers  from 
defective  nutrition. 

Apart  from  the  cases 
above  mentioned  of  para- 
lytic talipes,  where  the 
structures  are  loose  and 
flabby,  are  the  deformities 
in  which  contractures 
have  taken  place  as  a 
result  of  paralysis  of  cer- 
tain groups  of  muscles. 
Of  these  the  most  com- 
mon are  talipes  cavus 
(arcuatus  or  plantaris),  in 
which  after  paralysis  of 
the  extensors  of  the  foot 
the  muscles  and  liga- 
ments of  the  sole  and 
calf  contract,  producing 
varying  degrees  of  de- 
formity and  concavity  of 
the  sole  of  the  foot, 
together  with  elevation  of  the  heel  (equinus).  In  some  instances  the  pointing 
of  the  foot  produces  secondary  retraction  of  the  toes  (hollow  claw-foot)  by 
the  strain  of  the  extensors  of  the  toes.  The  distortion  resulting  from  the 
conflicting  forces  occurs  mainly  at  the  ankle  joint,  the  medio-tarsal  and  the 
metatarso-phalangeal  joints.  All  grades  of  deformity  are  met  with,  from 
slight  exaggeration  of  the  arch  of  the  foot  to  the  most  extreme  equinus. 
Much  more  rarely  the  converse  deformities  are  met  with  (fig.  178). 

In  slight  cases,  manipulation  or  the  use  of  artificial  muscles  without  any 
operation  will  remedy  the  distortion,  but  in  the  severer  forms  of  old- standing 
cavus  and  equinus,  division  of  the  tendo  Achillis,  or  of  more  or  fewer  of  the 
resisting  structures  in  the  sole,  will  be  required.     After  operation  an  artificial 

1  Brit.  Med.  Jour.  June  1884. 

3B 


Fig.  177. — Acquired  Talipes  following  measles,  probablj  due 
to  infantile  paralysis 


738 


Club-foot,  Deformities  of  Limbs,  &c. 


muscle  should  be  used,  and  kept  on  till  all  tendency  to  re-contract  has 
ceased.  In  troublesome  cases  of  '  cavus'  we  attach  the  artificial  muscle  to 
a  thin  steel  sole  plate,  which  is  modelled  to  fit  over  the  balls  of  the  toes, 
and  so  get  over  the  difficulty  of  the  tendency  of  the  foot  strap  to  slip  into 
the  hollow  of  the  foot.  Some  good  figures  of  these  cases  are  given  in  a 
paper  by  Mr.  F.  R.  Fisher,  '  Lancet,'  January  19,  1889. 

Patients,  the  subjects  of  club-foot,  often  suffer  from  complications  of  this 
condition.  Bursae  develop  over  the  points  upon  which  pressure  is  made,  and 
these  may  become  inflamed  and  suppurate,  giving  rise  to  obstinate  sores, 
which  will  not  heal  and  acquire  callous  edges.  In  some  cases  rest  and 
ordinary  treatment  suffice,  in  others  tarsectomy  or  even  amputation  may  be 
called  for.  PirogofFs  or  even  Chopart's  operation  should  usually  be  done 
in  such  cases  in  preference  to  Syme's  amputation. 

The  whole  foot  and  leg  in  severe  cases  is  smaller  and  weaker  than  the 
other,   and   often  shorter.      The   wasting   of  muscles,   &c.,  is    extreme    in 

some  instances,  even  when  no 
paralytic  condition  has  existed. 
The  movements  of  the  ankle- 
joint  become  altered,  and  it  de- 
velops into  a  ball-and-socket 
rather  than  a  ginglymoid  joint 
(Jorg).  The  metatarsal  bones 
are  usually  shorter  than  normal, 
a  condition  due  to  the  contraction 
of  the  plantar  fascia,  according  to 
Borck. 

Treatment  of  club-foot  in  all 
cases  must  be  kept  up  constantly 
until  all  tendency  to  relapse 
ceases.  Dr.  Little  remarks  that 
such  patients  require  watching 
until  puberty,  and,  as  already 
pointed  out,  the  result  depends 
entirely  upon  the  amount  of  care 
and  perseverance  expended  upon 
them. 

Relapsed  club-foot  after  teno- 
tomy is  much  more  difficult  to  treat  than  it  is  in  cases  where  nothing  has 
been  done  ;  tenotomy  should,  however,  be  repeated  and  the  usual  methods 
carried  out. 

Flat-foot.— Apart  from  congenital  and  paralytic  valgus  is  the  common 
condition  known  as  spurious  valgus,  pes  pronatus  acquisitus,  pes  planus,  or 
commonly  flat-foot.  Though  this  affection  is  not  by  any  means  peculiar  to 
childhood,  it  most  commonly  comes  on  in  the  later  years  of  childhood  or 
adolescence  ;  sometimes,  however,  it  occurs  earlier  (fig.  34  eiseq.). 

The  condition  is  essentially  one  of  relaxed  ligaments  and  muscles,  and 
comes  on  usually  in  weakly  overgrown  children,  who  have  been  kept  too 
much  on  their  feet — especially  if  they  are  rickety  also.  It  is  one  of  the 
conditions  arising  in  so-called  '  rickets  of  adolescence.' 


Fig. 


178. — Acquired  Talipes  calcaneus, 
infantile  paralysis. 


Flat-foot 


739 


The  prominent  part  assigned  to  relaxation  of  the  inferior  calcaneo- 
scaphoid  Hgament  in  the  production  of  flat-foot  is  hardly  deserved,  since  the 
tibial  muscles,  the  flexors  of  the  toes  and  poUex,  the  short  sole  muscles,  the 
plantar  ligaments,  the  plantar  fascia,  and  the  peroneus  longus  all  take  a 
share  in  supporting  the  arch,  and  the  condition  is  in  most  cases  the  local 
expression  of  a  widely  spread  weakness  rather  than  the  result  of  yielding  of 
any  one  structure.     In  a  few  cases  flat-foot  is  the  result  of  injury. 

Lowering  and  inward  projection  of  the  head  of  the  astragalus,  with  loss  ot 
the  arch  of  the  foot  and  its  elongation,  are  the  prominent  features  of  the 
affection.  The  sole  may  be  flat  or  even  convex,  and  the  inner  border  early 
becomes  convex  also  ;  there  is  usually  pain  over  the  head  of  the  astragalus 
often  also  across  the  dorsum  of  the 
foot  and  beneath  the  outer  malleo- 
lus, and  very  commonly  also  in  the 
first  metatarso-phalangeal  joint  (one 
form  of  'metatarsalgia').  Often 
the  patient  applies  for  relief  entirely 
because  of  the  pain  in  this  joint. 

The  prominent  projecting  mass 
<m  the  inner  aspect  of  the  foot  is 
not,  however,  by  any  means  always 
the  head  of  the  astragalus  only  ;  it 
is  often  the  tubercle  of  the  scaphoid, 
since  this  bone  is  frequently  pressed 
downwards  and  inwards  by  the 
astragalus,  so  that  yielding  takes 
place  rather  at  the  scapho-cunei- 
form  than  at  the  astragalo-scaphoid 
joint.  In  some  cases  the  promi- 
nence is  .shared  equally  by  the 
astragalus  and  scaphoid.  In  any 
case  where  the  deformity  is  marked 
there  is  a  deep  depression  on  the 
dorsum  of  the  foot,  due  to  the 
slipping  away  of  the  head  of  the 
astragalus. 

In  early  stages  the  deformity  is 
only  seen  when  the  patient  is  standing,  when  the  whole  foot  may  be  seen  to 
collapse  and  spread  out  in  a  toneless  fashion,  the  transverse  arch  also  giving 
way.  In  later  stages  the  foot  becomes  fixed  in  its  distorted  position,  and 
cannot  be  replaced.  In  intermediate  stages  replacement  is  possible  ;  some- 
times in  manipulating  the  foot  adhesions  give  way  and  the  arch  is  restored 
for  the  time.  These  adhesions  are  the  result  of  chronic  inflammatory 
changes  which  are  specially  prone  to  occur  in  the  metatai-so-phalangeal 
joint  of  the  great  toe,  but  may  attack  several  joints  and  the  sheaths  of  the 
tendons.  Occasionally  a  violent  spasm  of  the  tibial  muscles  is  seen  pulling 
the  foot  into  a  position  of  varus— this  is  a  sort  of  expiring  eftbrt,  and  when 
it  is  over  flat-foot  is  seen. 

The   treatment  of  this   disease  consists  in  preventing   the    child   from 

3   H2 


fig-  179- — Flat-foot  in  a  boy  aged  13^  years. 


740  Chib-foot,  Deformities  of  Limbs,  drc. 

standing  long  at  a  time,  and  improving  its  general  condition  ;  next,  the 
deformity  must  be  reduced  ;  in  ordinary  cases  an  artificial  muscle,  applied 
so  as  to  support  the  head  of  the  astragalus,  is  perfectly  efficient  in  relieving 
pain  and  restoring  the  arch  of  the  foot,  and  any  reasonable  amount  of 
standing  and  walking  can  be  done  from  the  first  as  soon  as  this  is  applied. 
It  is  the  only  form  of  apparatus  we  use  now,  and  it  very  seldom  fails  if 

properly  applied.  In  some  cases  it  may  be 
necessary  to  break  down  the  adhesions  first, 
but  in  children  this  is  rare.  It  is,  however, 
important  that  the  foot  be  moulded  into  good 
shape  each  night  and  morning. 

Standing  and  walking  on  tiptoe,  dancing, 
and  friction  are  all  useful  supplementary 
means,  as  pointed  out  by  Ellis,  who  is  of 
opinion  that  the  flexor  longus  pollicis  is  a 
very  important  factor  in  tying  together  the 
pillars  of  the  arch  of  the  foot  ('  Lancet,' 
February  9,  1884). 

No  operation  is  ever  required  for  acquired 
flat-foot  in  children. 

A  form  of  distortion  in  which  there  is  ad- 
duction of  the  foot,  or  rather  rotation  inwards, 
in  which  the  deformity  depends  upon  a  rota- 
tion of  the  whole  leg,  is  sometimes  met  with. 
It  gives  rise  to  the  condition  popularly  known 
as  '  duck-toes.'  The  unsightly  gait  may  be 
due  to  congenital  malposition  or  to  rickets  ; 
it  has  been  proposed  to  call  the  deformity 
'  club-leg,'  and  to  remedy  it  by  osteotomy  of 
the  femur  icicle  supra,  chapter  on  Rickety 
Deformities  ;  also  Parker,  '  British  Medi- 
cal Journal,'  Oct.  27,  1888). 

"Wry-neck  or  Torticollis  is  a  fairly 
common  affection  in  childhood,  and  may  be 
due  to  any  of  the  following  conditions  : 

I.   It  may  be  congenital,  probably  due  to 

malposition    in    utero — sometimes    to    mal- 

development,    as  in  a  case  of  our  own,    in 

which  wry-neck,  deficient  development  of  the 

external  ear,  mastoid  region,  and  lower  jaw 

co-existed    with    cleft    palate    and    mental 

deficiency.' 

It  may  result  from  injuries  at  birth,  lacerations  of  muscles,  &c.     Volk- 

has  found  the  sterno-mastoid   represented  by  a  band  of  cicatricial 

Sterno-mastoid  tumour  (p.  24)  is  sometimes  followed  by  torticollis, 

the  injured  muscle  subsequently  becoming  contracted.    We  have  had  several 

cases    in  which  there  was  a  history  of  sterno-mastoid  tumour  in  infancy. 

1  Intercalations  of  more  or  less  developed  vertebral  bodies  may  produce  wry-neck  of 

one  kind,  as  it  may  lateral  curvature. 


Fig.  180.  — Shows  an  'Artificial  Muscle 
applied  for  Flat-foot. 


mann 
tissue 


Wry -neck 


74t 


(See  D'Arcy  Power, '  Med.  Chir.  Trans.'  vol.  Ixxvi.  1894.)    Petersen,  however, 
thinks  the  haematoma  is  a  result  of  injury  to  the  previously  shortened  muscle. 

3.  It  may  be  spasmodic,  due  to  central  or  peripheral  nerve  lesions  or 
reflex  irritation. 

4.  It  may  result  from  suppuration  in  the  neck,  due  to  either  glandular 
abscesses  or  cervical  caries,  causing  matting  together  of  the  parts  and  con- 
tracture of  the  muscles, 

5.  Burns  or  other  injuries  may,  of  course,  produce  cicatricial  torticollis. 
In  its  most  simple  form  wry-neck  is  due  to  contraction  limited  to  one 

sterno-mastoid,  which  is  felt  as  a  hard  tight  cord  in  the  neck  ;  the  head  in 
such  cases  is  drawn  towards  the  shoul- 
der, and  the  face  turned  towards  the 
opposite  side  (fig.  181). 

Golding  Bird  '  is  inclined  to  con- 
sider the  condition  clue  to  a  cerebral 
lesion  analogous  to  the  cord  lesions  in 
infantile  paralysis. 

In  other  instances  the  sterno- 
mastoid  is  not  alone  affected,  but  the 
scalenes,  trapezius,  and  cervical  fascia 
contribute  to  the  deformity. 

Treatment. — In  slight  cases  in  quite 
young  children  regular  daily  stretch- 
ing and  manipulation  of  the  rigid 
muscles  may  suffice  to  get  rid  of  the 
deformity.  In  the  severer  forms  of  the 
affection  tenotomy  is  the  only  effectual 
treatment.  The  sterno-mastoid,  and 
sometimes  the  trapezius,  require  divi- 
sion. For  tenotomy  of  the  sterno- 
mastoid  the  knife  is  passed  through 
the  interval  between  the  two  heads,  and 
its  edge  turned  forward  against  each  in 
succession,  the  child's  head  being 
held  stretched  by  an  assistant.  Care 
must,  of  course,  be  taken  not  to  wound  the  anterior  jugular  vein  at  the  front 
edge  of  the  muscle,  or  the  external  jugular  at  the  posterior  border,  nor  to 
carry  the  knife  so  deeply  as  to  endanger  the  carotid  sheath.  We  usually 
divide  the  muscle  through  an  open  incision,  and  where  the  cervical  fascia  is 
also  tightly  contracted  it  is  necessary  to  divide  it,  and  in  such  cases  it  is 
certainly  safer  to  make  an  incision  over  the  muscle  and  gradually  dissect 
through  the  rigid  parts  in  an  open  wound.  Some  surgeons  prefer  to  divide 
the  muscle  at  its  middle.  Two  days  after  the  tenotomy  the  apparatus 
(fig.  182)  recommended  by  Mr.  Southam  should  be  applied.  The  following 
case  is  characteristic : 

Case.  —  Torticollis. — John  Wm.  G. ,  age  5  years  ;  admitted  August  5,  1885.    A  neurotic 
family  history  ;  the  child  has  never  been  strong  ;  the  deformity  is  congenital,  but  has  bean 


Fig.  181. — Congenital  Wry-neck. 


1  Guy's  Reports,  1890;  f/^/t?  also  Murray,  Liverpool  Med.  Chir.  Jour.  July  1892. 


742 


Club-foot,  Deformities  of  Limbs,  drc. 


getting  worse  lately,  and  is  increased  when  the  child  is  not  well  ;  has  lately  had  toothache 
on  the  left  side.  On  admission  the  left  sterno-mastoid  is  contracted  in  its  whole  extent, 
forming  a  firm  prominent  band  ;  the  interval  between  the  tendons  is  deeply  marked,  the 
sternal  tendon  being  the  most  prominent.  The  chin  is  rotated  i^  inch  from  the  middle 
line  downwards  and  to  the  right ;  the  platysma  is  also  prominent.  August  13,  tenotomy 
of  both  heads  through  the  interval ;  the  cervical  fascia  was  also  partially  divided.  Anti- 
septic operation  and  wood-wool  dressing.  14th,  no  pain  ;  the  head  was  packed  in  sand- 
bags. 17th,  a  plaster-of-Paris  jacket  was  put  on  with  hooks  fixed  in  it,  and  a  rubber 
muscle  was  apphed  parallel  to  the  right  sterno-mastoid,  attached  to  the  head  by  circular 

bands  of  strapping.  20th,'  another 
muscle  was  applied  in  a  corresponding 
position  at  the  back.  22nd,  made  out- 
patient. He  was  seen  subsequently, 
and  hardly  any  visible  deformity  re- 
mained. November  10,  1885,  quite 
well. 

Spasmodic  torticollis,  if  it  does 
not  yield  to  medical  treatment, 
may  require  stretching  or  resec- 
tion of  the  spinal  accessory  nerve 
— all  causes  of  reflex  irritation, 
carious  teeth,  worms,  otorrhoea, 
enlarged  glands,  &c.,  having  been 
previously  removed. 

The  other  forms  of  wry-neck 
require  treatment  on  general 
principles,  or  are  irremediable  ; 
special  care  must,  of  course,  be 
taken  not  to  overlook  the  presence 
of  cervical  caries. 

In  all  cases  of  wry-neck,  where 
manipulation  is  admissible,  steady 
and  regular  attempts  should  be 
made  to  remedy  the  distortion  ; 
friction  and  steady  stretching  of 
the  neck  with  the  hands  should 
be  tried,  and  the  child  made  to  practise,  before  a  looking-glass,  trying  to 
hold  the  head  straight.  To  supplement  these  means,  various  apparatus, 
collars,  &c.,  may  be  used  ;  the  one  we  have  found  most  efficient  is  that  figured 
for  use  after  tenotomy.  In  quite  young  children,  of  course,  no  voluntary 
help  from  the  child  can  be  obtained,  but  the  friends  must  be  instructed  what 
to  do,  and  in  older  patients  it  is  a  good  plan,  as  Mr.  Roth  has  pointed  out, 
to  get  the  child  familiar  with  the  exercises  before  the  tenotomy  is  performed, 
so  that  no  time  may  be  wasted  afterwards. 

Congenital  cases,  where  the  sterno-mastoid  alone  is  involved,  are  usually 
completely  curable  ;  many  of  the  spasmodic  cases  get  well  either  sponta- 
neously or  after  removal  of  some  source  of  irritation.  In  cases  where 
the  scaleni  are  involved  there  is  more  difficulty,  and  section  of  cervical 
nerves  or  of  these  muscles  may  be  desirable,  provided  a  suitable  case 
occur.     In  many  of  these  patients   the  face  is  undeveloped,  or   distorted 


Fig.  182. — Artificial  Muscle  applied  for  Wry-neck 
after  division  of  the  Sterno-mastoid.  A  Sayre's 
jacket  is  applied  to  the  trunk,  and  traction  made 
from  a  poroplastic  cap  or  ring  of  strapping. 


Skiagram  of  the  arm  and  chest  wall  in  a  case  of  IVIyositis  ossificans, 
showing  the  bony  spines  and  plates  in  the  muscles. 


Congenital  Deficiencies  of  Muscles — Tenosynovitis       743 

on   the  affected  side  ;    secondary  lateral   curvature  of  the  spine  may  also 
result. 

It  is  certain  that  the  condition  already  described  as  sterno-mastoid 
tumour  sometimes  leads  to  subsequent  development  of  torticollis  from  cica- 
tricial contracture  of  the  muscle  ;  in  the  many  cases  we  have  seen,  such 
result  has  followed  in  several  instances,  and  D'Arcy  Power  has  collected  a 
number  of  other  cases.     Op.  cit. 

No  treatment  is  required  for  the  sterno-mastoid  tumour  except  that  watch 
should  be  kept  for  the  slightest  sign  of  onset  of  the  torticollis,  and  suitable 
preventive  exercises  employed. 

Cong:enital  Deficiencies  and  IVXalformations  of  Muscles  are  often 
slight,  and  interesting  from  an  anatomical  rather  than  a  surgical  point  of 
view  ;  in  other  instances,  such  as  those  where  the  pectoral  muscles  are  absent, 
in  association  with  arrest  of  development  of  the  chest-wall,  the  malformations 
are  irremediable  ;  in  others,  again,  some  help  may  be  obtained  by  elastic 
cords  ('  artificial  muscles '),  or  possibly  by  the  transplantation  of  muscle 
flaps;  for  the  most  part,  however,  these  conditions  are  beyond  the  present 
reach  of  surgery. 

We  must  just  mention  the  very  rare  condition  known  as  myositis  ossificafis, 
of  which  a  remarkable  instance  was  lately  under  our  care.  The  patient  was 
a  child  of  six  years  old  ;  the  affection  began  about  a  year  before  and  was 
steadily  progressing  ;  cervical,  pectoral,  brachial,  abdominal,  intercostal,  and 
femoral  muscles  were  many  of  them  more  or  less  affected,  without  any 
disturbance  of  health  so  far.  No  cause  is  known  for  the  disease,  and  no 
treatment  seems  to  be  of  any  avail  ;  the  subjects  of  it  usually  die  from 
interference  with  the  respiratory  movements  or  some  intercurrent  illness, 
though  they  may  live  for  years  (Plate  II.). 

Tenosynovitis  is  an  affection  common  in,  but  by  no  means  peculiar  to, 
childhood.  Tuberculous  tenosynovitis  is,  however,  not  rare,  usually  as  a 
secondary. condition  to  joint  disease,  but  occasionally  occurring  alone  ;  its 
existence  is  to  be  suspected  when  swelling  and  suppuration  occur  in  the 
course  of  a  tendon  in  a  tuberculous  subject,  and  its  treatment  must  be  on 
general  principles — rest  and  constitutional  measures  in  early  stages,  and 
careful  scraping  out  in  the  severer  ones.  We  have  once  or  twice  seen  sup- 
puration in  the  large  palmar  sheath,  and  in  one  instance  it  occurred  in  a 
premature  child  only  a  few  weeks  old,  coming  on  without  assignable  cause  ; 
secondary  pyaemic  abscesses  elsewhere  followed,  but  the  child  ultimately 
got  quite  well. 

Bursae  in  children  are  not  usually  very  well  developed.  Patellar  bursitis 
is,  however,  not  very  rare,  and  we  have  seen  it  lead  to  disease  of  the  knee- 
joint  ;  the  olecranon  bursa  is  also  occasionally  enlarged,  while  effusion  into 
the  semi-membranosus  bursa  is  not  uncommon.  Ganglion  is  most  common 
in  the  radial  extensor  tendons  and  in  those  of  the  thumb  ;  in  recent  cases  the 
fluid  may  be  dispersed  by  pressure,  in  others  it  should  be  punctured  with  a 
grooved  needle  and  the  clear  gelatinous  contents  let  out  ;  a  pad  with  firm 
pressure  should  be  kept  on  for  three  weeks  afterwards,  or  the  sac  is  likely  to 
refill.  In  obstinate  cases  the  sac  should  be  laid  open  and  as  much  of  it  as 
possible  dissected  away. 

malformations. — Other  congenital  malformations  may  be  conveniently 


744  Club-foot,  Deformities  of  Limbs,  &c. 

considered  as  (i)  those  due  to  errors  of  growth  in  the  embryo  itself — in- 
herent errors  ^ — and  (2)  those  due  to  abnormal  intra-uterine  surroundings- 
acquired  errors  ;  or  they  may  be  classified  as  deformities  by  excess,  deformi- 
ties by  deficiency,  and  deformities  by  distortion.  In  either  case  it  is  some- 
what difficult  to  assign  to  their  proper  place  all  the  malformations  met  with,, 
and  fortunately  it  is  of  little  practical  importance,  as  far  as  treatment  goes, 
that  we  should  do  so. 

Among  inherent  errors  may  be  classed  supernumerary  fingers  and  toes — 
polydactylism  ;  some  cases  of  webbed  fingers  and  toes — syndactylism  ;  tri- 
podism  ;  congenital  tumours  of  the  dermoid  class — with  which  might  be  put 
the  cases  of  so-called  foetal  inclusion.  Possibly  certain  less-marked  malfor- 
mations, such  as  those  affecting  only  some  of  the  structures  of  a  limb,  con- 
genital varices,  venous  and  lymphatic,  congenital  muscular  abnormalities, 
&c.,  should  be  placed  here,  though  these,  in  so  far  as  they  are  of  surgical 
importance,  are  more  conveniently  considered  under  the  organs  to  which 
they  belong.  Many  instances  of  inherent  errors  are  better  seen  in  the  head 
and  trunk,  such  as  a  failure  of  closure  of  the  dorsal  and  ventral  laminae  and 
of  the  visceral  arches  of  the  head,  meningocele,  spina  bifida,  harelip,  extro- 
version of  the  bladder,  &c. 

Among  acquired  errors  are  all  those  due  to  intra-uterine  pressure,  either 
by  the  walls  of  the  uterus  itself,  by  amniotic  bands  (Gurlt),-  by  pressure  or 
violence  applied  to  the  uterus  from  without,  or  by  mere  malposition  of  the 
foetus  in  utero,  at  whatever  period  of  gestation  they  arise. 

In  considering  what  malformations  should  be  placed  in  this  group,  we 
must  remember  that  it  is  probable  that  pressure  or  violence  acting  in  a  very 
early  stage  of  development  leaves  much  less  obvious  signs  of  injury  than  if 
it  is  inflicted  at  a  later  period  ;  thus  constriction  or  pressure  during  the  later 
months  of  pregnancy  may  leave  distinct  cicatrices,  while  the  same  forces 
applied  earlier  may  cause  deficiencies  without  any  marks  of  violence  or 
scars.^ 

In  this  group  will  be  placed  deficiency  of  limbs,  fingers,  &c.  (intra-uterine 
amputation),  as  examples  of  the  highest  degree  of  deformity  ;  also  congenital 
constrictions  and  dimples,  together  with  congenital  synostoses  or  deficiencies 
of  parts  or  the  whole  of  a  limb,  such  as  absence  of  one  or  more  of  the  carpal 
or  tarsal  bones,*  of  the  lower  end  of  the  radius  or  ulna,  causing  club-hand  ;, 
or  mere  faults  of  position  such  as  are  found  in  club-foot,  flexed  or  hyper- 
extended  joints,  &c. 

The  proof  that  some  of  these  deformities  are  the  result  of  errors  of  the 
embryo,  and  others  of  abnormalities  of  the  environment  (intra-uterine 
pressure,  &c.),  is  in  many  cases  easy,  in  others  impossible.  Thus  polydac- 
tylism and  congenital  tumours  cannot  be  the  result  of  intra-uterine  pressure, 

1   '  Vices  of  conformation.' 

^  Or,  as  Montgomery  has  pointed  out,  by  bands  of  lymph  stretching  from  one  part 
of  the  foetus  to  another ;  cf.  Intra-uterine  Amputation,  p.  746,  and  vide  Todd's  Encyclo- 
pcedia. 

5  Vide  Med.  Chir.  Trans.  1877  for  a  case  of  complete  absence  of  both  upper  limbs 
without  any  scar  ;  this  was  supposed  not  to  be  due  to  amputation. 

*  Bryant  {Diseases  of  Children)  records  a  case  of  congenital  absence  of  the  fibula,  os 
calcis,  cuboid,  and  three  outer  toes  ;  and  this  is  not  a  very  rare  malformation. 


Iiitra-uterinc  Aiitputation  745 

while  congenital  deficiency  of  limbs  is  shown  to  be  at  least  sometimes  due  to 
constriction  by  the  fact  that  the  amputated  limb  has  been  found  lying  loose 
in  titero^  and  in  other  instances  the  limb  has  been  found  incompletely 
severed,  or  even  an  unhealed  stump  has  been  present.  On  the  other  hand, 
the  absence  of  the  amputated  limb,  and  the  smooth  scarless  appearance  of 
the  stump  sometimes  met  with,  may  be  explained  by  the  fact  that  the  limb 
may  become  disintegrated  by  maceration  in  tdero,  and  if  the  separation 
took  place  at  a  very  early  stage  the  scar  might  disappear  during  growth  or 
become  indistinguishable  from  its  small  size.  Pressure,  again,  might  well 
produce  entire  arrest  of  growth  of  a  limb  without  amputation,  and  thus 
no  scar  would  be  left,  while  in  other  cases  pressure  might  produce  fusion  of 
l^arts  together,  as  in  web  fingers.'^  Evidence  in  favour  of  this  is  afforded  by 
the  co-existence  of  amputations  with  webbed  fingers  (both,  in  such  cases,  the 
result  of  pressure,  though  even  here  the  webbed  condition  may  have  been 
due  to  mere  retarded  development  from  constriction). 

Case. —  Web  Fingers  and  Toes,  Sfc. — Albert  B. ,  age  9  months  ;  admitted  November  2, 
1885.  No  history  of  deformity  or  maternal  impression.  Left  hand,  second  and  third 
fingers  are  united  as  far  as  the  first  interphalangeal  joint ;  there  is  no  nail  on  the  first  finger, 
a  very  imperfect  nail  on  the  second.  Right  hand,  the  first  finger  has  a  deep  constriction 
around  the  last  phalanx,  with  a  bulbous  enlargement  of  the  end  of  the  finger  ;  the  second 
finger  has  a  similar  constriction,  but  the  part  beyond  is  small  and  almost  without  nail. 
There  is  a  very  deep  constriction  round  the  right  leg,  about  one  inch  above  the  ankle, 
almost  reaching  to  the  bone.  The  child  can  stand  on  the  leg  and  moves  the  foot  freely. 
Left  foot,  there  is  only  one  phalanx  in  the  great  toe,  and  no  nail ;  the  nail  of  the  second 
toe  is  very  rudimentary,  and  there  is  a  small  outgrowth  on  the  fourth  toe.  Right  foot, 
toes  perfect,  but  the  foot  is  hypertrophied  and  flat.  November  5,  Didot's  operation  on 
the  hand.  7th,  healing  well.  12th,  stitches  removed  ;  flaps  have  united  largely,  but  there 
is  some  granulating  surface.  Sent  home  on  November  13.  The  flaps  subsequently  gave 
way  partially,  but  were  again  nearly  healed,  when  the  child  died  at  home  of  broncho- 
pneumonia. 

Suppression  of  an  intermediate  segment  of  a  limb,  as  where  fingers  are 
found  springing  from  a  stump  of  the  upper  arm,  is  probably  due  to  pressure. 

Again,  inherent  and  acquired  errors  may  co-exist,  and  would  be  likely  to 
do  so.  A  local  overgrowth  of  the  embryo  might  well  disturb  the  relation 
between  the  uterus  and  its  contents,  and  lead  to  deformity  by  pressure.- 

Lastly,  reversion,  atavism,  and  so  on,  must  not  be  left  out  of  sight  in 
considering  these  questions,  which  cannot,  however,  be  further  discussed 
here." 

Whether  double  monsters,  dermoid  cysts  of  the  ovary  and  testis,  and 
congenital  tumours  of  various  kinds  are  the  result  of  fcetal  inclusion,  partheno- 
genesis, or  gemmation,  is  a  question  that  cannot  be  entered  upon  here  ;  it 
will  be  sufficient  to  say  that  some  cases  are  certainly  the  result  of 'fused' ^ 

1  Web  fingers  are,  however,  no  doubt  in  most  cases  due  to  mere  persistence  of  the 
foetal  spade-like  condition  of  the  hands. 

2  Deficient  development  of  one  half  of  the  body,  with  facial  paralysis,  has  been  met 
with  (Barker,  Clin.  Soc.  Trans.  1884). 

5  Vide  Bland  Sutton's  Lecture,  Lancet,  1887-8  ;  also  Ballantyne's  Antenatal 
Pathology. 

4  '  If  during  development  the  medullary  fold  remains  cleft,  two  complete  foetuses  are 
formed  from  a  single  ovum,'  and  every  degree  of  combination  from  twins  to  very  rudimen- 
tary '  parasitic'  foetuses  may  result.     (Bland  Sutton,  Lancet,  February  11,  1888.) 


746 


Club-foot,  Deformities  of  Limbs,  &c. 


embryos — e.g.  double  monsters,  adherent  twins,  and  so  on — while  some  con- 
genital tumours  are  equally  certainly  mere  errors  in  the  closing  in  of  the 
folds  of  the  blastoderm  or  of  the  local  involutions  by  which  certain  organs 
are  formed.^  We  have  recently  had  a  remarkable  case  of  abdominal  tumour 
in  a  child  three  months  old  which  proved  to  be  an  included  foetus  lying  in 
the  lesser  cavity  of  the  peritoneum. 

Supernumerary  dig-its  are  found  attached  in  various  ways  ;  thus,  a  mere 
little  fleshy  outgrowth  with  or  without  a  nail,  and  with  no  bony  support,  may 
be  attached  to  a  more  or  less  normal  finger,  or  the  end  of  a  finger  may  be 
bifid,  with  two  nails.  In  other  instances  a  supernumerary  thumb  with  two 
phalanges  may  spring  from  the  joint  between  the  '  metacarpal '  bone  and  the 
first  phalanx,  a  common  joint  existing  for  the  two  thumbs,  or  the  extra  one 
may  be  attached  to  the  side  of  the  proper  one.  It  is  sometimes  not  easy  to 
make  out  which  is  the  supernumerary  and  which  the  natural  digit  ;  in  such 
cases  the  most  useful  one  should,  of  course,  be  left. 

In  any  case  of  supernumerary  fingers  the  additional  one  should  be 
removed  in  infancy,  so  as  to  allow  the  other  as  far  as  possible  to  be  trained 


Fig.  183. — Double  Thumb. 


Fig.  184.  —  Intra-uterine  Amputation  of  Fingers. 


into  its  proper  position.  Where  a  joint  is  common  to  the  two  fingers  care 
must  be  taken  not  to  injure  the  articulation  nor  to  allow  it  to  suppurate,  for 
fear  of  a  stiff  joint  resulting.  Supernumerary  toes  should  be  removed  if 
they  cause  distortion  of  the  foot  or  are  likely  to  lead  to  trouble  in  wearing 
ordinary  boots. 

For  figures  and  details  of  the  different  forms  of  polydactylism  we  must 
refer  to  Annandale's  work  on  '  Diseases  of  the  Fingers  and  Toes.' 

Occasionally  cases  are  met  with  where  more  or  less  of  a  limb  is  deficient, 
and  the  member  ends  in  a  pointed  or  truncated  extremity  like  an  amputation 
stump  ;  this  may  occur  at  any  point  in  the  length  of  a  limb.  Sometimes 
only  parts  of  one  or  more  digits  are  deficient,  sometimes  the  amputation  has 
been  incomplete,  and  a  deep  sulcus  round  the  finger  or  limb,  with  often  a 
bulbous  expansion  on  the  distal  side  of  it,  marks  the  seat  of  pressure.  This 
constriction  in  some  cases  is  so  tight  that  there  appears  to  be  little  left 
undivided  except  the  bone,  and  this  condition  we  have  met  with  associated 


'  Numerous   figures   and   references  will   be   found    in   Forster's   AlissMldufigen   des 
Menschen. 


'~1 


Skiagram  of  a  case  of  Club  Hand,  with  arrest  of  development  of  the 
radial  (praeaxial)  border  of  the  limb. 


Club-hand 


747 


with  talipes  ;  the  movements  of  the  limbs  were,  however,  good,  and 
evidently  the  deeper  structures,  though  compressed,  were  not  divided.  We 
have  also  seen  these  constrictions  associated  with  dimpled  depressions  over 
the  knees  and  shoulders,  and  rigidity  of  the  joints,  also  the  result  of  intra- 
uterine pressure  ;  in  one  instance  there  was  also  microcephalus.  Most  of 
the  cases  of  intra-uterine  amputations,  and  of  these  constrictions,  are  the 
result  of  pressure  by  amniotic  bands  or  foetal  adhesions,  as  already  pointed 
out ;  but  it  is  undoubtedly  occasionally  true  that  pressure  by  the  umbilical 
cord,  so  gradually  exerted  as  not  to  interfere  with  its  own  circulation,  may 
produce   the    same    effect.'      We   have    not    seen    a   case    of   constriction 

requiring  any  operation,  though  it  has 
been  suggested  by  Mr.  Edmund  Owen 
to  pare  the  adjacent  surfaces  and  unite 
them  so  as  to  obliterate  the  groove. 


Fig.  185. — Congenital  Arrest  of  Develop- 
ment of  one  Lower  Limb. 


Fig.  186. — '  Club-hand,'  so  called.  There  is 
absence  of  the  radius  and  thumb  with  ab- 
duction of  the  hand. 

Nothing,  of  course,  can  be  done 
for  congenital  amputation  except  the 
use  of  prothetic  appliances,  and  it  is 
wonderful  what  use  these  patients  can 
make  of  their  stumps.  As  already 
pointed  out,  in  some  instances  there  is  a 
distinct  scar,  in  others  a  smooth  unbroken  cutaneous  surface,  and  sometimes 
rudimentary  digits  remain  attached  to  the  end  of  a  stump  containing  only 
the  humerus  or  femur  ;  this  is  rather  an  arrest  of  growth  by  pressure  than  a 
true  amputation.  So,  too,  sometimes  the  femur  or  humerus  is  congenitally 
very  short  or  deficient.     (Fig.  185.) 

Club-hand,  so  called,  is  a  somewhat  rare  affection,  resulting  from  arrest 
of  development  of  more  or  less  of  the  radius  or  ulna,  with  consequent 
abduction  or  adduction  of  the  hand  (Plate  III.).  It  is  not  in  any  sense 
really  comparable  to  the  ordinary  forms  of  club-foot,  and  is  little  amenable  to 
treatment.  Something,  however,  may  be  done  by  manipulation  to  remedy 
the  deformity  and  possibly  encourage  growth  of  the  shortened  bone  by 
friction  and  removal  of  pressure.  Less  often  the  hand  is  fixed  in  flexion  or 
1    Vide  Neville,  B7-it.  Med.  Jotir.  1883,  p.  209. 


748 


Club-foot,  Defo7'mities  of  Limbs,  &c. 


hyper-extension,  and  in  these  cases  sometimes  tenotomy  may  be  required. 
Similar  deformities  may,  of  course,  result  from  cicatricial  contraction  after 
injury.  In  one  instance  the  radius  was  entirely  deficient  on  both  sides,  and 
the  ulna  was  fractured  and  repaired,  probably  hi  titero.  At  the  suggestion 
of  one  of  our  Resident  Medical  Officers,  Mr.  J.  H.  Thompson,  we  trans- 
planted some  bone  from  another  child  into  an  incision  between  the  muscles 
of  the  forearm.  The  wound  healed  perfectly,  and  the  bone  was  growing  at 
the  time  of  the  child's  death  from  an  independent  cause  two  or  three  weeks 
later  ;  the  position  of  the  hand  was  much  improved.  Careful  bandaging 
and  the  use  of  splints  will  do  good  in  some  cases  if  treatment  is  begun  early. 
•Web  Fing-ers. — Various  degrees  of  this  deformity  are  met  with  :  thus 
there  may  be  a  mere  extension  of  the  normal  web  forwards  to  the  first  inter- 

phalangeal  joint.  In  other  in- 
stances metacarpal  bones  and 
phalanges  may  be  fused  to- 
gether, or  bound  in  very  close 
contact  throughout  the  whole 
length  of  the  digit  :  occasion- 
ally the  union  is  only  at  the 
distal  ends  ^  {vide  anted).  The 
deformity  is  usually  more  or 
less  perfectly  symmetrical,  and 
often  associated  with  a  similar 
condition  in  the  feet  or  with 
some  other  deformity. 

Where  there  is  complete 
bony  fusion  of  two  adjacent 
digits  no  attempt  should  be 
made  to  separate  them  ;  where, 
however,  only  skin  and  sub- 
cutaneous tissue  unite  the  two 
fingers,  they  should  be  sepa- 
rated. Simple  division  of  the 
web  is  of  little  use,  since  the 
wound  granulates  up  from  the  bottom  and  more  or  less  reunion  occurs. 

Several  plans  have  been  devised  to  meet  this  difficulty,  such  as  applying 
an  elastic  cord  between  the  fingers  and  fastening  it  round  the  wrist  after 
division  of  the  web  ;  perforating  the  base  of  the  web  and  putting  a  thread  or 
wire  through  the  orifice  and  allowing  it  to  heal,  and  then  dividing  the  web. 
Another  mode  consists  in  dividing  the  web  and  then  bringing  a  flap  of  skin 
from  the  dorsum  or  palm  across  between  the  fingers  so  as  to  interpose  a 
bridge  of  skin  at  the  base  (Norton).  The  best  plans  are  the  last-mentioned 
and  that  advocated  by  Didot,  in  which  a  dorsal  flap  from  one  finger  and  the 
web,  and  a  palmar  flap  from  the  other  finger  and  the  palmar  aspect  of  the 
web,  are  cut ;  the  rest  of  the  web  is  then  divided,  and  the  flaps  are  wrapped 
round  the  raw  surface  of  the  finger  to  which  they  remain  attached.     In 


-Double  Club-hand 


1  This  could  hardly  be  the  result  of  failure  of  the  natural  differentiation  of  the  fingers 
in  foetal  life,  which  results  from  the  phalanges  outgrowing  the  webs. 


Congenital  Rigidity  of  Joints 


749 

doing  this  operation,  however,  it  will  be  found  that  there  is  not  sufficient 
skin  to  cover  both  fingers,  and  one  has  to  heal  by  granulation.  Web  toes 
do  not  require  treatment. 

Cong-enltal  Rlgridlty  of  Joints  and  Contractions. — As  already  stated, 
children  are  sometimes  born  with  joints,  chiefly  the  knees,  elbows,  and 
shoulders,  whicli  are  stiff,  or,  on  the  other  hand,  unduly  lax  ;  and  sometimes 
these  joints  arc  fixed  in  flexion,  sometimes  hyper-extended,  or  at  least  hyper- 
extensible.  In  such  cases  there  are  not  rarely  marks  of  pressure  about  the 
joints — depressions  and  adhesions 
of  the  skin.  Probably  the  condi- 
tions determining"  such  deformities 
are  like  those  causing  talipes,  viz. 
intra-uterine  pressure  or  malposi- 
tion ;  thus  the  "  genu  recurvatum ' 
sometimes  seen  results  from  the 
limbs  being  packed  in  hyper- 
extension  along  the  ventral  surface 
of  the  body  (figs.  i88,  189)  ;  it  is 
sometimes  described  as  congenital 
dislocation  of  the  knee.  In  these 
patients  the  patella  is  usually  either 
absent  or  very  small  ;  it,  however, 
develops  as  the  position  and  mo- 
bility of  the  knee  are  improved  by 
treatment.  The  rigidity  and  hyper- 
extension  of  the  joint  may  be 
almost  perfectly  overcome  by  suit- 
able exercises  and  apparatus. 
Failure  of  developmental  rotation 
accounts  for  other  deformities. 

Diligent  friction  and  passive 
movement,  together  with  the  appli- 
cation of  sphnts,  as  the  individual 
deformity  may  require,  will  some- 
times effect  great  improvement  ;  ^ 
in  other  instances  little  success 
attends  treatment. 

One  or  more  of  the  fingers  or 
toes  may  be  congenitally  contracted 
either  in  flexion  or  extension  ;  the 
contraction,  often  slight  at  first, 
tends  to  increase  as  the  child  grows. 


Fig.  18S.     Genu  recurvatum  and  Talipes  calcaneus, 
from  sketch  by  the  late  Mr.  C.  F.  Sutton. 

Hammer-toe  is  a  result  of  this  condi- 


tion.    In  most  instances  it  has  been  shown  that  contraction  of  the  ligaments 
of  the  inter-phalangeal  joints  is  the  cause  of  the  deformity. 

We  have  met  with  a  non-congenital  form  of  contraction  of  the  terminal 


•  Berkeley  Hill  records  a  good  casein  which  there  was  so  much  rotation  that  the  heels 
looked  directly  forwards.  By  the  use  of  apparatus  and  tenotomy  an  almost  perfect  result 
was  obtained.— 7?r//.  A/e,/.  Jour.  July  12,  1884  ;  vide  also  1883. 


750  Club-foot,  Deformities  of  Limbs,  &c. 

joints  of  the  index  and  middle  fingers.  The  skin  and  fascia  were  the  structures 
affected,  just  as  in  Dupuytren's  contraction.  According  to  Adams,  the  Httle 
finger  is  more  often  affected,  and  the  deformity  is  said  to  be  markedly 
hereditary,  and  to  be  commonly  associated  with  a  history  of  'hammer- 
toe.' ' 

Stretching  and  simple  splints,  in  ordinary  cases,  is  the  treatment  required. 
If  neglected,  troublesome  corns  or  bunions  and  distortion  of  the  nails  may 

result  from  pressure  of 
boots.  Division  of  the 
lateral  ligaments,  or  in  some 
cases  resection  of  a  joint  or 
part  of  the  shaft  of  a  pha- 
lanx, or  even  amputation, 
may  be  the  best  treatment 
for  hammer-toe. 

'  Hallux  flexus,'  first 
described  by  Mr.  Davies 
Colley,  is  defined  as  a 
'  progressive  diminution  in 
the  normal  range  of  exten- 
sion of  the  great  toe.'  It 
causes  lameness,  is  patho- 
logically closely  allied  to 
hammer-toe,  and  requires 
treatment  by  rest  followed 
by  manipulation  and  fric- 
tion, and  in  severe  cases  by 
division  of  the  lateral  liga- 
ments or  osteotomy.  Vide 
also  '  Metatarsalgia,'  p. 
739.  Hallux  valgus  and 
other  deviations  of  the  toes 
ar'e  rarely  serious  in  chil- 
dren, and  are  usually  amen- 
able to  treatment  by  splints, 
or  wearing  of  boots  and  socks  with  stalls  for  the  toes.  So-called  '  toe-post ' 
boots  are  very  useful  for  these  cases. 

It  must  be  remembered  that  some  of  these  patients  with  distorted  Hmbs 
are  cases  of  cerebral  deficiency,  and  for  them  of  course  little  can  be  done. 

Cong;enital  Dislocations,  so  called,  of  almost  any  joint  may  be  met  with  : 
thus  the  temporo-maxillary,  elbow,  and  wrist  joints,  the  joints  of  the  spine,  toes, 
&c.,  have  been  found  displaced,  though  such  deformities  are  by  far  most  fre- 
quently met  with  in  the  hip.  These  conditions  have  been  variously  explained : 
injury  i7i  utero  or  at  birth,  intra-uterine  inflammations,  convulsions,  pressure, 
nervous,  bony,  and  muscular  lesions  have  all  been  assigned,  as  in  club-foot,  as 
causes  of  congenital  dislocations.     It  is  most  probable  that,  as  in  club-foot, 


g.  189. — Abnormal  position  in  utero,  causing  genu  recur- 
vatum  and  talipes  calcaneus,  &c.,  from  sketch  by  the  late 
Mr.  C.  F.  Sutton. 


1  Adams,  Lancet,  December  13, 
August  1891, 


also  i8qi  ;  and  Anderson's  Lectures,  Lancet, 


PLATE    IV. 


'Congenital   Dislocation'  of  the  hip.     The  acetabulum  is  seen  fai-  below 
the  head  of  the  femur. 


Congenital  Dislocation  of  the  Hip 


751 


intra-uterine  pressure  from  malposition  is  the  most  frequent  cause,  though 
not  the  only  one.  In  all  cases  more  or  less  deformity  of  the  bony  articular 
surfaces  is  found,  and  this  is  of  the  utmost  importance,  since  it  largely  pre- 
vents the  possibility  of  anything  like  complete  reduction. 

In  'congenital  dislocation'  of  the  lower  jaw  the  condyle  and  glenoid 
cavity,  as  well  as  much  of  the  bony  framework  of  that  side  of  the  skull,  have 
been  found  stunted.  Occipito-atlantoid  dislocation,  both  backward  and 
forward,  has  been  described  ;  in  the  former  the  head  is  flexed,  in  the  latter 
hyper-extended. 

Dislocations  of  the  clavicle  in  the  varieties 
met  with  in  later  life  are  also  mentioned  by 
Guerin. 

The  humerus  may  be  displaced  down- 
wards, forwards  (subcoracoid),  or  backwards 
(subspinous),  with  arrest  of  growth  of  muscle 
and  bone,  and  deviation  from  the  normal 
shape  of  the  articular  surfaces.^  Displace- 
ments of  the  elbow  and  wrist  have  also  been 
met  with.'-  The  most  important  of  all  these 
malformations  is  Congrenital  Dislocation 
of  the  Hip,  since  it  is  by  far  the  most  fre- 
quent, and  sometimes  seriously  incapacitates 
the  subject  of  it.  In  these  cases  the  ace- 
tabulum is  small,  shallow,  and  may  be  filled 
with  fat  or  '  webbed  over  ; '  the  head  of  the 
femur  may  be  nearly  normal  or  much  stunted. 
A  more  or  less  perfect  capsule  may  be 
present,  and  this  may  be  thickened  ;  or, 
again,  a  sort  of  interosseous  ligament  may 
exist  :  the  ligamentum  teres  is  atrophied, 
the  muscles  around  the  joint  are  wasted. 
The  affection  may  be  unilateral  or  more  often 
bilateral.  The  femur  is  usually  freely  movable 
and  slides  up  and  down  upon  the  dorsum  ilii 
to  an  extent  of  sometimes  two  inches  or 
more  (Plates  IV.,  V.). 

The  affected  limb  or  limbs  are  usually 
imperfectly  developed  throughout.  There  is 
al\\ays  a  good  deal  of  lameness  in  severe  cases,  though  we  have  met  with 
slight  degrees  of  this  deformity  in  which  the  joint  was  not  very  much 
altered.  There  are  marked  lordosis  and  a  peculiar  'waddling'  way  of 
walking  which  is  very  characteristic.  Usually  the  displacement  is  upwards 
and  backwards,  but  it  may  be  in  almost  any  direction  ;  the  limbs  are 
sometimes  adducted  markedly. 


Fig.  igo. — i'Congenital  Dislocation 
of  both  Hps.      Not  a  severe  case.. 


>  Dislocation  of  the  htiinerus  appears  to  be  often  associated  with  other  conditions  of 
malformation  ;  in  a  case  shown  us  by  our  friend  Mr.  C.  E.  Richmond  tliere  were  sub- 
spinous dislocation  of  the  shoulder  and  dislocation  of  both  hips.    See  Chapter  on  INJURIES. 

2  See  Hamilton's  work  on  Frachcrcs  and  DislocatioTis. 


y'C,2  Club-foot,  Deformities  of  Limbs,  &c. 

Besides  the  ungainliness  of  the  walk,  it  is  possible  that  the  deformity  of 
the  pelvis  may,  as  Adams  suggested,  be  important  from  an  obstetric  point  ot 
view.  There  is  little  to  be  done  for  these  cases,  though  it  has  been  recom- 
mended that  the  affected  limb  should  be  supported  and  fixed  in  a  state  of 
extension,  and  it  is  said  that  a  certain  amount  of  increased  stability  in  the 
joint  may  result.^  Section  of  the  muscles  surrounding  the  joint,  and  even 
excision,  as  well  as  scarification  of  the  deeper  tissues  and  hollowing  out  the 
surface  of  the  ilium,  have  been  practised  with  the  object  of  giving"  increased 
stability  to  the  joint,  but  it  is  unlikely  that  any  of  these  plans  will  gain  favour. 
Hoffa's  mode  of  operating  has  been  tried  in  a  number  of  cases,  but  published 
results  do  not  encourage  further  attempts  in  this  direction.  Prolonged  ex- 
tension in  bed  we  have  found  do  harm  rather  than  good,  though  some 
successful  cases  have  been  recorded.  When  the  affection  is  unilateral  a 
thick-soled  boot  on  the  short  limb  will  improve  the  gait,  and  in  some  cases 
a  pelvic  girdle,  with  pads  to  support  and  fix  the  end  of  the  femur,  has  been  of 
service.  Long  walks  and  long  standing  should  be  avoided,  but  we  cannot 
recommend  any  operative  treatment.  The  history  of  the  case,  the  absence  of 
pain  and  rigidity,  and  the  peculiar  gait  distinguish  the  affection  from  hip 
disease.  Rickety  lordosis  sometimes  closely  resembles  congenital  dislocation, 
but  careful  examination  of  the  relative  positions  of  the  trochanters  and  iliac 
spines  will  prevent  a  mistake.  The  affection  is  by  no  means  rare.  [See 
also  Coxa  Vara,  p.  211].  The  various  operative  methods  of  treating  this 
condition,  though  much  recommended  by  their  inventors,  have  failed  to 
prove  themselves  justifiable.  The  bloodless  methods,  such  as  reduction 
(Paci)  by  manipulation,  are,  though  harmless,  httle  more  successful.  It  is 
probable  that  most  of  the  successful  cases  have  been  instances  of  traumatic 
dislocation  at  or  after  birth,  and  not  of  developmental  deficiency. 

So-called  Cong-enital  Dislocation  of  the  Knee  has  been  already  men- 
tioned as  '  genu  recurvatum  ; '  this  joint  is  also  occasionally  found  with  partial 
backward  or  lateral  displacement.  If  seen  in  quite  early  infancy,  these  de- 
formities are  fairly  amenable  to  treatment  by  manipulation  and  splints,  and 
we  have  been  able  to  completely  remedy  the  deformity  of '  recurved  knee' 
by  these  means  {vide  figs.  188,  189). 

Besides  the  deformities  already  described,  it  is  necessary  just  to  men- 
tion the  occurrence  of  cases  of  Congenital  rissure  of  the  Sternum  from 
non-union  of  the  different  centres  of  ossification,  or  rather  non-closure  of  the 
ventral  laminee,  sometimes  associated  with  ectopia  cordis.  Cases  of  deficiency 
of  the  ribs  over  a  larger  or  smaller  area,  and  lack  of  development  of  the 
muscles  of  the  chest-wall  and  of  the  mammary  glands,  may  be  met  with  ;  we 
have  seen  hernia  of  the  lung  through  a  gap  of  this  sort.  ( Vide  Thompson, 
'  Teratologia,'  January  1895.) 

Cong'enital  Deficiency  of  one  or  both  Clavicles  or  of  the  Scapula 
may  also  be  occasionally  seen.  A  suprascapula  has  been  met  with,  attaching 
the  scapula  to  the  vertebrae,  and  requiring  removal  (Willett  and  Walsham, 
'  Med.  Chir.  Trans.'  1 883).    Deficiency  or  imperfect  development  of  the  patella 

'  Mr.  Adams,  Brit.  Med.  Jour.  February  1890,  relates  cases  illustrating  the  value  of 
prolonged  extension,  and  figures  appliances,  Vide  also  Lovett  on  Disease  of  the  Hip, 
Boston,  1892,  and  papers  in  the  Annals  of  Surgery ,  1895.     Also  Tubby  On  Deformities,  ^c. 


'Congenital   Dislocation'  of  the  hip,  the  fellow  to  Plate  IV. 


Dcfonnities  of  Limbs,  &€.  753 

sometimes  occurs  ;  it  is  usually  absent  in  cases  of  genu  recurvatum.  Many 
other  normal  conditions  may  occur — some  deficiencies,  some  excesses,  as 
in  the  common  cases  of  supernumerary  mamm;e,  which  are  doubtless  instances 
of  reversion,  and  so  on  ;  but  these  cannot  be  discussed  here.  Many  require 
no  treatment  ;  others  must  be  dealt  with  on  general  rules.  Occasionally  pro- 
tective shields  may  be  required  for  such  cases  as  thoracic  hernia.  The 
works  of  Ballantyne  and  Tubby  should  be  consulted  for  recent  accounts  of 
these  malformations,  as  well  as  papers  by  many  American  surgeons  in  the 
'  Annals  of  Surgery,'  and  elsewhere. 


3  <^ 


754  Diseases  of  the  Nose 


CHAPTER   XXXIV 

DISEASES    OF    THE    NOSE 

The  oi-ifices  of  the  anterior  nares  are  a  favourite  seat  of  eczema,  lupus,  and 
superficial  tuberculous  ulceration  ;  other  cutaneous  affections  and  nasvi  are 
also  often  met  with  upon  the  surface  of  the  nose  :  vide  Chapters  XXXVIII 
and  XIX. 

The  nasal  cavities  in  children  are  exceedingly  often  the  seat  of  acute  or 
chronic  catarrh,  the  result  of  cold,  or  extension  from  the  pharynx.  Catarrh 
also  commonly  occurs  in  rickety,  tuberculous,  or  syphilitic  children. 

Acute  Catarrb  is  generally  simply  mucous  ;  it  may,  however,  become 
purulent,  or  may  be  so  from  the  first,  especially  if  it  is  the  result  of  inocula- 
tion, which  may  occur  at  birth  or  accidentally  at  a  later  period. 

Chronic  ITasal  Catarrh  is  marked  by  discharge  of  muco-purulent  material 
from  the  nose,  swelling  of  the  mucous  membrane  and  of  the  skin  of  the 
anterior  nares,  with  often  some  thickening  of  the  upper  lip  from  irritation  ; 
the  voice  is  nasal,  respiration  is  impeded,  deafness  is  often  present,  the 
child  snores,  and  in  an  infant,  suckling  is  often  difficult,  sometimes  impossible, 
from  obstruction  to  breathing  through  the  nose.  Occasionally  the  inflam- 
mation extends  to.  the  antrum,  nasal  duct,  or  frontal  sinuses.  On  examin- 
ing the  nose  the  interior  is  seen  to  be  red  and  angry-looking,  often  slightly 
excoriated  ;  it  easily  bleeds,  and  there  are  frequently  dried  scabs  on  its  surface, 
while  stringy  mucus  is  apt  to  collect  upon  the  lips  in  neglected  children  and 
give  rise  to  soreness.  Where  one  nostril  alone  is  affected,  careful  search 
must  be  made  for  one  of  three  conditions  :  a  foreign  body,  such  as  a  button, 
a  bit  of  slate  pencil,  or  a  date-stone,  &c.  ;  a  mucous  polypus  growing  from  the 
region  of  the  inferior  or  middle  turbinated  bone — a  somewhat  rai'e  condition 
in  childhood  ;  or,  thirdly,  a  deviated  nasal  septum. 

Chronic  catarrh,  from  whatever  cause,  is  apt,  if  neglected,  to  give  rise  to 
ozaena  from  decomposition  of  the  retained  secretion,  or  from  caries  or 
necrosis  of  the  bones  of  the  fossce  ;  where  the  bones  are  involved  the  foetor 
is  more  intense  than  in  other  cases. 

Should  the  inflammation  extend  to  the  cartilaginous  and  bony  septum, 
the  nose  may  lose  its  support,  by  softening  of  these  structures,  and  become 
flattened  and  depressed.  Where  the  outer  walls  are  more  especially 
attacked,  a  broad  thickened  nose  results.  In  most  cases  these  deformities 
occur  in  connection  with  congenital  syphilis  rather  than  in  tubercular  or 
simple  bone  lesions.  A  probe  will  usually  detect  the  presence  of  bare  bone, 
and  it  must  be   remembered  that  in  cases  of  apparently  simple  polypi  a 


Chronic  Nasal  Catarrh  755 

patch  of  exposed  bone  will  often  be  felt.  Bleeding  from  the  nose  in  these 
affections  occurs  often  in  small  amounts,  but  rarely  to  any  serious  extent. 

Diagnosis.— The  existence  of  chronic  nasal  catarrh  is  obvious  ;  its  cause 
requires  looking  for,  and  this  should  be  done  systematically.  First,  if 
unilateral,  the  causes  already  mentioned — foreign  body,  deviated  septum, 
or  polypus — are  to  be  suspected.  If  double,  the  throat  should  be  examined 
for  enlarged  tonsils,  chronic  pharyngitis,  and  post-nasal  adenoid  growths. 
Evidence  of  congenital  syphilis  or  tuberculosis  may  be  obtained,  or  some- 
times simply  carious  teeth  or  eczema  may  be  the  source  of  the  trouble. 

Treatment- — -If  the  cause  is  local,  an  antissthetic  should  be  given,  and  the 
foreign  body,  post-nasal  growths,  &c.,  removed.  To  remove  a  foreign  body 
from  the  nose,  a  simple  loop  of  silver  wire  is  useful,  or  a  pair  of  dressing 
forceps  or  a  small  scoop  may  be  employed  ;  sometimes  a  finger  passed  from 
the  mouth  into  the  posterior  nares  is  of  service,  and  occasionally  the  simplest 
plan  is  to  push  the  foreign  body  backwards  into  the  pharynx  and  remove  it  from 
the  mouth.  In  one  of  our  cases  the  body,  a  button,  escaped  into  the  pharynx 
while  the  child  was  under  chloroform,  and  was  found  in  the  vomit  brought 
up  by  the  child  on  its  awaking".  In  syphilitic  and  tuberculous  cases  syringing 
out  with  warm  alkaline  lotions  (sodii  bicarb,  gr.  xx  ;  aq.  3J)i  or  iii  older 
children  the  nasal  douche,  is  the  most  efficient  means  of  clearing  away  the 
crusts  ;  this  should  be  done  three  or  four  times  daily,  and  subsequently 
powdered  boric  acid  or  tannic  acid  and  iodoform  in  equal  parts  should  be 
blown  into  the  nose  through  a  quill  or  insufflator,  or  the  nasal  cavity  may 
be  brushed  over  with  glycerine  of  tannin  or  lead  lotion.  Sometimes  a  spray 
may  be  substituted  for  the  syringing  after  the  nose  is  once  cleared.  Solution 
of  hydrochlorate  of  cocaine,  5  to  10  per  cent.,  may  be  used  as  a  spray  or 
brushed  on,  either  before  removing  a  foreign  body  or  in  cases  of  acute  catarrh. 
Cleanliness  and  care  of  the  general  health,  with  mercury  or  iodide  of  potassium, 
or  both  together,  according  to  the  child's  age,  are  required  in  syphilitic  cases. ^ 
Any  sequestra  should  be  removed  as  early  as  possible,  and  all  foul  crusts 
kept  constantly  cleared  away.  Cod-liver  oil  and  iron,  with  the  usual  hygienic 
measures  and  careful  cleansing  of  the  nose,  together  with  iodoform  insuffla- 
tion, is  the  best  treatment  for  the  tuberculous  cases.  Nitrate  of  silver,  gr. 
x-xxx  to  3J,  is  sometimes  used  with  advantage  as  an  occasional  application. 
In  nearly  all  chronic  cases  the  prognosis  is  somewhat  uncertain,  and  the 
course  of  the  disease  tedious.  Where  the  above-mentioned  methods  fail,  and 
especially  in  tuberculous  ulceration  of  the  nasal  mucous  membrane,  an 
antesthetic  should  be  given  and  the  affected  parts  well  scraped  with  a 
Volkmann's  spoon,  or  cauterised  with  the  wire  cautery. 

Nasal  obstruction.,  apart  from  the  causes  just  mentioned  and  those 
already  described  under  Diseases  of  Tonsils,  &c.,  may  be  due  to  deviation  of 
the  cartilaginous  septum.  This  is  sometimes  congenital — more  often  it  is  the 
result  of  fracture  of  the  septum,  or  dislocation  from  either  the  ethmoid  or 
vomer,  or  from  the  nasal  spine  of  the  upper  jaw  ;  or,  again,  it  may  be  the 
result  of  a  chronic  perichondritis,  following  an  injury,  and  resulting  in  soften- 
ing and  subsequent  deviation  of  a  local  patch  of  the  septum.     If  the  whole 

1  In  infants  mercury  alone,  in  children  over  three  or  four  years  iodide  of  potassium 
alone,  or,  failing  a  good  result,  combined  with  mercury,  is,  we  find,  the  most  successful 
plan. 

3  C2 


756  Diseases  of  the  Nose 

cartilage  is  involved,  there  will  be  some  flattening  of  the  end  of  the  nose  ; 
this,  however,  does  not  usually  occur.  Simple  chronic  perichondritis,  causing 
thickening,  h^ematoma  of  the  septum,  or  abscess,  or  even  ecchondrosis 
of  the  cartilage  may  also  be  met  with.  The  treatment  of  deviated  septum 
consists  in  forcible  straightening  with  a  pair  of  guarded  sequestrum  forceps 
or  with  Adams's  special  instrument ;  and  the  subsequent  wearing  of  a  nasal 
plug,  such  as  Walsham's  or  the  one  devised  by  one  of  the  present  writers,  or, 
best  of  all,  a  piece  of  rubber  drainage  tube,  is  required.  In  some  cases 
removal  of  the  projecting  mass  is  called  for  :  in  such  circumstances  the 
muco-perichondrium  should  be  dissected  up  and  laid  down  again  after 
removal  of  the  cartilage.  Ha^matoma,  if  it  does  not  subside,  is  best  treated 
by  incision — so  also  abscess  ;  usually  in  both  cases  incision  on  one  side  will 
empty  the  sac  on  both  sides,  since  the  cartilage  is  perforated.  Dislocation 
is  best  treated  by  the  use  of  plugs.  Lateral  deviation  of  the  nose  visible 
externally  ('crooked  nose')  sometimes  requires  the  use  of  special  appliances 
to  be  worn  to  correct  the  deformity.  For  an  account  of  some  cases  see 
paper  in  '  Medical  Chronicle,'  vol.  iv.,  1886. 

Ifasal  Polypi  are  somewhat  rarely  met  with  in  childhood  ;  they  spring 
from  the  region  of  the  middle  or  inferior  turbinated  bones  as  soft,  grey, 
semitransparent,  rounded  masses  ;  occasionally  they  take  origin  higher  up 
in  the  nasal  cavity.  Repeated  removals  with  the  use  of  astringents  in  the 
intervals  is  the  treatment  required.^  The  polypi  should  be  taken  away  with 
forceps  ;  in  some  cases  the  tendency  to  re-growth  is  so  obstinate  that  it  is 
necessary  to  take  away  the  whole  of  the  turbinated  bone  from  which  the 
growths  arise. 

Where  there  is  nasal  obstruction  from  chronic  catarrh  or  cicatricial  con- 
traction, the  use  of  nasal  bougies  or  plugs  smeared  with  any  medicament 
desired,  such  as  iodide  of  lead  or  iodoform  ointment,  is  useful. 

Superficial  ITlceration  of  the  mucous  membrane  of  the  nose  often  occurs 
in  cases  of  chronic  catarrh  from  any  cause,  and  occasionally  the  ulcers  are 
deeper  and  lead  to  perforation  of  the  septum  ;  this  is  especially  likely  to  occur 
from  pressure  of  foreign  bodies.  We  have  seen  perforation  of  the  septum 
occur  in  a  child  simply  from  picking  the  nose.  Perforation  of  the  septum 
from  tuberculous  ulceration  is  fairly  common  and  very  intractable.  The 
ulceration  may  or  may  not  be  associated  with  lupus  of  the  adjacent 
skin. 

Chronic  Dry  Catarrh  of  the  nose,  accompanied  by  atrophy  of  the  turbi- 
nated bones  and  their  coverings,  may  be  met  with  ;  it  is  often  associated  with 
ozEena.  The  treatment  is  similar  to  that  of  ordinary  chronic  catarrh,  but, 
according  to  Sir  M.  Mackenzie,  the  use  of  medicated  plugs  of  wool  relieves 
some  cases.  The  disease  is  a  very  intractable  one  :  painting  with  glycerine 
is  occasionally  useful. 

Con§reiiital  IVXalformations  of  the  nose  are  rare  ;  closure  of  the  anterior 
or  posterior  nares,  adhesions  between  the  walls  of  the  nasal  fossae,  perfora- 

1  Acid,  tannic-.,  parts  ii  ;  cupri  sulphat.,  part  i  ;  pulv.  plumbi  nitrat.,  part  g,  will  be 
found  a  good  snuff  for  these  cases  if  obstinate  ;  the  milder  applications  mentioned  under 
Chronic  Catarrh  are,  however,  often  sufficient.  The  occasional  application  of  nitrate 
of  silver  fused  on  a  wire  is  sometimes  required. 


Nasal  Polypi.     Ilpistaxjs  757 

tiun  of  tlic  septum,  and  cases  of  cleft  or  flattened  nose,  or  even  of  entire 
deficiency  of  tlie  organ,  have  been  met  with.' 

Malig-nant  Polypi  of  the  nose  and  nasopharynx  are  occasionally  seen  in 
children  ;  early  removal  is  the  only  treatment,  but  speedy  recurrence  is  to  be 
looked  for. 

Epistaxls  occurs  very  frequently  in  children,  sometimes  as  a  result 
merely  of  cerebral  congestion,  the  communication  between  the  longitudinal 
sinus  and  the  nasal  veins  remaining  open  in  early  childhood  ;  in  other  cases 
congestion  from  catarrh,  or  ulceration,  injury,  or  foreign  bodies,  &c.,  may 
give  rise  to  bleeding.  Hasmophilic  patients  frequently  bleed  from  the  nose, 
and  epistaxis  is  a  complication  often  met  with  in  some  of  the  exanthems,  &c. 

Usually  the  bleeding  ceases  spontaneously  in  a  short  time  ;  if  this  is  not 
so,  bathing  with  cold  water,  or  a  little  ice  applied  inside  or  over  the  nose, 
will  usually  stop  the  flow.  Astringent  powders  or  lotions,  tannin,  alum,  &c., 
may  be  blown  into  the  nostrils.  Sometimes  pressure  from  outside  is  effectual  ; 
in  other  cases  making  the  child  stand  upright,  with  the  arms  above  the  head 
so  as  to  expand  the  chest  and  relieve  venous  engorgement,  will  prove  suc- 
cessful. 

Occasionally  the  nose  may  require  plugging. 

Nasal  Deformity. — Where  there  is  destruction  of  the  whole  or  part  of 
the  nose,  plastic  operations  may  be  employed.  These  must  be  planned 
according  to  the  individual  requirements  of  the  case.  We  are  rather  of 
opinion  that  a  good  artificial  nose  is  preferable  to  most  of  those  obtained  by 
plastic  operations.  Where,  however,  there  is  loss  of  only  a  small  part  of  the 
nose,  or  where  there  is  flattening  without  loss  of  substance,  attempts  should 
be  made  to  improve  the  appearance  of  the  child  by  filling  up  the  gap  or  ele- 
vating the  depressed  part.  It  will  be  found  that  there  is  great  difficulty  in 
obtaining  a  good  prominent  nose  by  any  method,  and  too  much  should  not 
be  promised.  For  details  of  the  methods  of  operating  we  must  refer  to 
systematic 'works  on  Operative  Surgery. 

1  For  tigs,  of  deformities  vide  Forster's  Misshildungcn  des  Mensc/ien. 


758  Diseases  of  the  Ear 


CHAPTER   XXXV 

DISEASES    OF    THE    EAR 

Biseases  of  the  External  Ear. — The  auricle  may  be  congenitally 
absent  or  crumpled  and  distorted  :  for  the  former  condition  an  artificial  ear 
may  be  fitted,  for  the  latter  usually  nothing  can  be  done. 

In  cases  of  deficient  development  of  the  pinna  the  ramus  of  the  jaw  may 
also  be  stunted — i.e.  the  first  post-oral  arch  and  its  appendages  may  be  ill 
developed.^ 

For  an  account  of  supernumerary  auricles  and  fistulse,  vide  p.  178. 

Sometimes  the  ear  is  unduly  large,  and  stands  out  prominently  from  the 
side  of  the  head  ;  the  appearance  may  be  improved  by  the  use  of  an  ear 
truss,  or  in  extreme  cases  by  removal  of  a  triangular  portion  of  the  ear  and 
careful  closure  of  the  gap  by  sutures,  or  excision  of  a  portion  of  the  skin  and 
cartilage  from  the  posterior  surface  of  the  pinna,  or  by  suturing  the  ear  to 
the  skin  covering  the  mastoid  process. 

The  pinna  is  often  the  seat  of  eczema  and  chilblains,  which  require  the 
treatment  of  the  same  affections  elsewhere  ;  eczema  most  commonly  attacks 
the  crease  between  the  auricle  and  the  side  of  the  head,  and  chilblains  the 
free  edge  of  the  ear. 

Simple,  lupous,  or  other  tuberculous  ulceration  may  also  attack  the  ear, 
and  we  have  seen  the  whole  auricle  rapidly  slough  away  during  an  attack 
of  whooping-cough. 

The  orifice  of  the  external  meatus  is  sometimes  congenitally  closed  :  in 
such  cases,  if  the  tuning-fork  shows  the  labyrinth  to  be  healthy,  a  careful 
dissection  may  be  made  at  the  site  of  the  orifice,  or  the  meatus  may  be 
reached  by  incision  behind  the  auricle  and  the  orifice  afterwards  opened 
upon  a  bent  probe.  Nothing  should  be  attempted  until  the  child  is  old 
enough  to  have  the  hearing  power  tested,  unless  there  is  evidence  of  retained 
secretion  giving  rise  to  abscess,  when  an  opening  must  be  at  once  made. 

The  common  affections  of  the  external  meatus,  which  in  children  is  pro- 
portionately shallower  and  broader  in  a  horizontal  direction  than  in  adults, 
are  eczema,  boils,  accumulations  of  wax  or  epidermis,  and  the  presence  of 
foreign  bodies  :  the  first  are  not  peculiar  to  children  ;  the  last  is,  of  course, 
commoner  in  them.  If  the  foreign  body  has  passed  beyond  the  orifice  of 
the  meatus,  it  should  be  removed  by  gently  syringing,  or  by  means  of  a  loop 
of  silver  wire,  or  by  a  probe  coated  with  cobbler's-wax  or  glue.     No  violence 

'  As  in  a  case  of  Canton's,  Path.  Soc.  Trans,  vol.  xv.  We  have  had  similar  cases 
under  oiar  own  care. 


Inflaniviatioii  of  Middle  Ear  759 

should  be  used,  and  it  is  better  to  leave  a  foreign  body  where  it  is  than  to 
push  it  further  in  or  lacerate  the  meatus  or  membrana  tympani  in  attempts 
at  its  removal.  Insects,  &c.,  in  the  meatus  are  readily  killed  by  a  drop  or 
two  of  oil. 

Eczema,  tuberculous  sores,  &c.,  may  give  rise  to  purulent  discharge  from 
the  ear,  but  usually  such  discharge  comes  from  the  middle  ear.  In  all  cases 
the  pus  should  be  carefully  soaked  up  with  absorbent  wool  and  the  ear 
examined  ;  sometimes,  however,  the  meatus  is  so  swollen  and  the  child  so 
intractable  that  no  examination  can  be  made  :  under  such  conditions  the 
case  should  be  treated  as  one  of  otitis  media  until,  either  with  or  without 
anaesthesia,  the  ear  can  be  examined. 

The  imperfect  development  of  the  tympanic  bone  and  consequent  shal- 
lowness of  the  meatus  in  children  must  be  borne  in  mind  ;  in  young  infants 
the  membrane  lies  in  a  more  horizontal  plane  than  in  adults. 

Inflammation  of  tbe  IVIiddle  Ear  maybe  either  acute  or  chronic.  The 
causes  of  acute  otitis  are  catarrh  of  the  nasopharynx,  usually  associated  with 
enlarged  tonsils  or  post-nasal  adenoid  growths,  cold,  and  the  exanthems, 
especially  scarlet  fever  ;  injuries  also,  by  picking  or  roughly  drying  out  the 
ear  with  corners  of  towels  and  so  on,  may  rupture  the  membrane  and  set  up 
otitis  media. 

Case. — Chronic  To7isilliiis.  Post-nasal  Adenoid  Growths.  Deafness.- — Annie  C,  age 
9  years  ;  admitted  July  i,  1884.  Always  healthy  till  scarlet  fever  four  years  ago,  when 
she  had  sore  throat,  running  from  nose,  and  deafness  ;  worse  lately.  On  admission,  ton- 
sillar aspect ;  health  otherwise  fair  ;  both  tonsils  bulge  forwards  and  inwards  ;  nasal 
mucous  membrane  thickened  ;  upper  part  of  pharynx  stuffed  full  of  warty  adenoid  growths  ; 
posterior  nares  nearly  blocked.  July  24,  pharynx  cleared  with  finger,  curette,  and  Volk- 
mann's  spoon  ;  left  tonsil  removed,  bled  freely  ;  much  clearer  afterwards.  Result,  great 
improvement.     February  1885,  quite  well. 

Sir  W.  Dalby  ^  has  pointed  out  that  boxing  the  ears  of  children  may 
give  rise  to  nervous  deafness  without  a  rupture  of  the  membrana  tympani, 
such  deafness  being  usually  permanent  and  severe  ;  or  the  membrane  may  be 
ruptured  :  in  such  case  the  rupture  may  heal  or  be  followed  by  inflammation 
of  the  middle  ear  ;  or,  lastly,  acute  otitis  may  be  set  up  without  rupture  of 
the  membrane. 

In  otitis  the  result  of  throat  affections  the  disease  may  be  caused  either 
by  Eustachian  obstruction,  and  consecjuent  retention  of  secretion,  or  by  actual 
extension  of  the  inflammation  along  the  tube.  The  symptoms  are  pain  in 
the  ear  and  head,  deafness,  and  some  constitutional  disturbance.  In  infants, 
who  cannot  indicate  the  seat  of  their  trouble,  otitis  should  be  suspected  if 
there  are  fretfulness  and  restlessness,  with  tossing  about  of  the  head  without 
other  assignable  cause.  If  these  cases  are  left  to  themselves,  the  membrane 
soon  yields,  and  a  purulent  discharge  escapes  from  the  meatus,  giving 
usually  great  relief ;  until  discharge  appears  the  condition  is  often  overlooked 
in  scarlet  fever,  where  the  attention  is  apt  to  be  directed  to  other  symptoms. 
If  the  membrane  is  examined  in  such  cases,  there  will  be  seen  all  the  signs 
of  inflammation,  redness  and  loss  of  lustre,  and  if  pus  is  present  it  may 
perhaps  be  visible  as  a  yellow  discoloration  of  the  lower  part  of  the  mem- 
brane. 

1  Brit.  Med.  Jour.  December  23,  1882. 


760  Diseases  of  the  Ear 

Treatment. — The  throat  must  be  attended  to,  and  antiseptic,  sedative,  or 
astringent  appH cations  used,  according" to  circumstances;  next,  the  Eustachian 
tube  must  be  kept  open  by  PoHtzer^s  method  :  the  inflation  can  be  performed 
at  the  moment  of  the  child's  crying.  Hot  fomentations,  with  perhaps  a  leech 
behind  and  in  front  of  the  ear,  and  instillation  of  a  drop  of  glycerine  and 
laudanum,  or  glycerine  and  carbolic  acid,  into  the  meatus,  should  be  employed. 
Failing  relief  by  these  means,  the  membrane  should  be  carefully  mcised, 
either  horizontally  or  vertically,  behind  the  handle  of  the  malleus,  and  the 
discharge  allowed  to  escape — gentle  washing  out  of  the  ear  with  warm 
boric  lotion,  and  inflation  of  the  middle  ear,  being  also  used.  As  soon  as 
the  acute  symptoms  have  passed  off,  powdered  boric  acid  and  iodoform 
should  be  blown  into  the  ear  after  drying  it  carefully  with  absorbent  wool 
two  or  three  times  daily,  according  to  the  amount  of  discharge. 

The  dangers  of  otitis  media  are  manifold  :  first,  deafness  ;  and  secondlj^, 
extension  of  inflammation,  which  may  reach  the  mastoid  antrum  or  the 
mastoid  cells,  perforate  the  roof  of  the  tympanum,  or  the  sutura  petro- 
mastoidea,  which  is  still  open  in  infancy,  and  so  directly  reach  the  brain. 
Cerebral  abscess  and  meningitis  are  not  remote  dangers.  Or  the  carotid 
artery  may  be  opened  by  ulceration  and  fatal  bleeding  ensue  ;  or  throm- 
bosis of  the  lateral  sinus  and  pyemia  may  result.  Extension  of  mischief 
to  the  temporo-maxillary  joint  may  occur,  with  stiffness  of  the  articulation. 
The  amount  of  deafness  depends  rather  upon  the  injury  done  to  the  laby- 
rinth, upon  interference  with  the  mobility  of  the  ossicles,  or  upon  fixation  of 
the  stapes,  than  upon  destruction  of  the  membrana  tympani. 

The  dangers  to  hfe  are  to  be  met  by  providing  free  drainage  for  discharge 
and  keeping  the  cavity  aseptic  as  far  as  possible.  If  there  is  any  pain, 
swelling,  or  tenderness  over  the  mastoid  process,  an  incision  should  be  at 
once  made  down  upon  it  ;  if  no  pus  is  reached  and  the  symptoms  are  urgent, 
the  bone  must  be  carefully  gouged  away  just  behind  and  level  with  the  roof 
of  the  meatus  until  the  cavity  of  the  antrum  is  reached.  It  must  be  remem- 
bered that  in  children  the  mastoid  cells  are  not  well  developed  and  vary 
much  in  size,  and  that  the  lateral  sinus  descends  less  than  half  an  inch 
behind  the  meatus.  Swelling  and  tenderness  over  the  mastoid  process 
does  not  always  mean  inflammation  of  the  mastoid  antrum  or  cells,  but  may 
be  the  result  of  extension  superficially  of  inflammation  of  the  meatus  or  of 
irritation  of  the  mastoid  lymphatic  gland.  Even  if  pus  is  not  reached 
at  the  time,  relief  may  be  given  and  an  easier  way  for  discharge  made  ;  but 
the  removal  of  bone  should  be  free  if  the  symptoms  are  definite,  and, 
if  possible,  an  opening  should  be  made  through  which  lotion  can  be 
syringed  into  the  external  meatus.  In  neglected  cases  extensive  necrosis 
may  occur,  and  the  walls  of  the  meatus,  or  even  the  greater  part  of  the  petrous 
bone,  may  come  away  as  sequestra.  It  is  common  to  find  the  lymphatic 
glands  just  below  the  ear  inflamed,  and  they  may  cause  much  pain,  or  may 
suppurate  and  discharge  through  the  walls  of  the  meatus.  In  the  early  stages 
of  glandular  inflammation,  hot  belladonna  fomentations  will  often  arrest  the 
mischief;  if  suppuration  occurs,  the  abscess  should  be  early  incised. 
Suppurative  meningitis,  if  diffuse,  is  not  amenable  to  treatment,  but  localised 
cerebral   abscess,  which  may  be  either  in  the  temporo-sphenoidal   lobe  or 


Otitis  Media  761 

cerebellum,  should  he  treated  by    trephining    the    skull    and    opening    the 
abscess. 

Facial  paralysis,  which  not  uncommonly  results  from  otitis  media,  is 
peripheral,  and  the  result  of  pressure  upon  the  nerve  in  the  wall  of  the 
tympanum  ;  the  paralysis  usually  disappears  on  subsidence  of  the  otitis,  but 
may  be  permanent.  Chronic  otitis  media  may  be  due  to  the  same  causes 
as  the  above,  but  is  often  tuberculous  ;  it  may  last  for  years,  and  give  rise  to 
occasional  attacks  of  acute  earache.  Chronic  otitis  is  always  a  source  of 
danger,  and  should  never  be  neglected  ;  the  tympanic  cavity  should  be  care- 
fully cleansed  by  gentle  syringing,  and  then  the  mucous  membrane  got  into 
a  healthy  state  by  insufflation  daily  of  the  iodoform  and  boric  powder,  or 
by  the  use  of  slight  astringents,  such  as  alum,  gr.  iij  to  5J,  or  sulphate  of  zinc, 
gr.  j-ij  to  3J  ;  boric  and  carbolic  lotions  are  perhaps  the  most  generally 
useful.  On  examination  of  the  ear  in  these  cases  the  membrane  is  usually 
almost  entirely  gone,  and  the  ossicles  more  or  less  completely  destroyed  ;  the 
hearing  power  is  impaired,  but  seldom  entirely  lost.  The  complications  met 
with  in  the  acute  variety  are  also  liable  to  occur  at  any  time  in  the  course  of 
a  chronic  case.  Small  perforations  of  the  membrane  in  children  readily 
heal,  but  it  is  exceptional  to  meet  with  them. 

In  very  chronic  otorrhcea  masses  of  granulation  tissue,  springing  from  the 
tympanic  cavity,  less  often  from  the  membrane  or  walls  of  the  meatus,  may- 
appear,  and  form  the  commonest  kind  of  aural  polypus  ;  fibrous,  mucous,  and 
adenomatous  polypi  are  much  rarer.  Polypi  are  to  be  treated  by  removal 
with  forceps,  or  scraping  away,  and  the  application  of  some  caustic,  of  which 
we  prefer  solid  nitrate  of  silver  fused  on  a  loop  of  wire  ;  crystals  of  per- 
chlorrde  of  iron  or  chromic  acid  may  be  used  if  preferred,  and  the  ear  should 
be  washed  out  with  a  solution  of  rectified  spirit  as  strong  as  can  be  borne 
without  pain  (usually  i  in  4  to  1-2  can  be  employed).  Boric  and  tannic 
acid  and  iodoform  insufflations' should  be  used  between  times.  It  is  often 
necessary  to  remove  these  polypi  several  times  before  they  cease  growing. 
All  abscesses  burrowing  about  the  ear  must  be  opened  and  well  drained,  and 
the  general  health,  as  well  as  the  condition  of  the  throat  and  nose,  carefully 
looked  after.  Eustachian  catheters  require  an  anaesthetic  in  children,  and 
should  only  be  used  when  Politzer's  method  fails. 

The  general  routine  method,  then,  of  treating  otorrhcea  ('  otitis  media 
suppurativa')  may  be  given  thus,  (i)  Dry  out  the  ear  with  absorbent 
wool.^  (2)  Examine  with  a  speculum,  and  through  this  puff  a  powder  of 
equal  parts  of  iodoform  and  boric  acid,  once,  twice,  or  three  times  daily, 
according  to  the  amount  of  discharge.-  (3)  Inflate  the  ear  by  Politzer's 
method  once  daily.  (4)  Watch  for,  and  open  early,  any  mastoid  or  glan- 
dular abscess.  (5)  Protect  from  cold,  and  take  care  of  the  general  health.'^ 
(6)  Never  neglect  the  least  earache.  (7)  See  that  the  throat  and  naso-pharynx 
are  healthy. 

1  Where  hospital  patients  cannot  be  seen  dail)'  the  friends  should  syringe  out  the  ear 
with  warm  boric  lotion. 

-  We  prefer  a  simple  speculum  and  the  use  of  an  aural  reflecting  mirror,  but  Brinton's 
■  otoscope  '  may  be  used. 

^  A  clean  plug  of  absorbent  wool  should  be  put  into  the  meatus  and  changed  two  or 
three  times  daily  or  more,  according  to  the  amount  of  discharge. 


762  Diseases  of  the  Ear 

It  must  be  remembered  that  pain  in  the  ear  may  be  a  result  of  carious 
teeth,  cervical  adenitis,  or  any  source  of  pressure  upon  the  nerves  supplying 
the  auricle  or  meatus,  as  well  as  of  ear  disease.' 

Affections  of  the  Iiabyrinth  in  children  may  be  either  congenital,  or  the 
result  of  injury,  or  of  extension  from  otitis  media,  or  of  congenital  syphilis. 
The  latter  form  usually  comes  on  about  the  seventh  to  twelfth  year,  increases 
rapidly,  affects  one  ear  first,  and  leads  to  severe  or  total  deafness  ;  it  is 
rarely  remediable,  though  mercury  and  iodide  of  potassium  should  be  tried. 
-If  the  case  comes  under  treatment  in  an  early  stage,  there  is  some  hope  of 
recovery.  Deafness  in  children  should  be  seen  to  at  once,  and  care  should 
be  taken,  in  those  in  whom  restoration  of  hearing  cannot  be  complete,  to 
make  them  read  and  speak  aloud  to  prevent  the  tendency  to  become  mutes. 
Deaf-mutes  should  be  taught  the  'oral  method.' 

Intracranial  Abscess. — Should  there  be  evidence  of  intracranial  abscess, 
as  shown  by  fever,  vomiting,  otorrhoea,  pain  in  the  side  of  the  head,  convul- 
sions, squint,  hemiplegia,  more  or  less  loss  of  consciousness,  and  perhaps  optic 
neuritis,  the  ear  should  be  examined  and  well  cleaned  out,  so  as  to  avoid 
any  further  retention  of  pus  in  the  tympanum  ;  a  flap  of  soft  parts  should  then 
be  turned  up  by  a  curved  incision,  exposing  the  temporal  bone  above  and 
behind  the  ear  ;  a  circle  of  bone  should  then  be  gouged  away,  having  its 
centre  opposite  the  posterior  superior  cjuadrant  of  the  meatus,  and  from  \  in. 
to  I  in.  from  the  meatus,  according  to  the  age  of  the  patient.^  Having  removed 
the  bone,  if  no  sign  of  abscess  appears,  the  dura  mater  should  be  incised  and 
the  brain  punctured  first  directly  inwards,  then  forwards  and  inwards,  and 
finally  backwards,  so  as  to  tap  any  abscess  situated  either  in  the  cerebrum 
or  cerebellum  ;  if  pus  is  found,  the  opening  should  be  enlarged,  and  the 
abscess  drained  and  treated  on  general  principles.  The  mastoid  antrum 
and  cells,  if  not  previously  cleaned  out,  should  be  dealt  with  at  the  same  time. 
( Vide  also  p.  498.)  Barker  points  out  that  a  single  rigor,  followed  by  sub- 
normal temperature,  slow  pulse,  and  '  sluggish,  but  perfect,  cerebration,'  may 
be  met  with  in  cerebral  abscess.  There  appears  to  be  no  certain  means  of 
distinguishing  temporo-sphenoidal  from  cerebellar  abscess,  but  in  the  latter 
the  pain  is  usually  occipital,  and  there  is  retraction  of  the  head  ;  the  amount 
of  paralysis  in  either  case  is  inconstant.  Temporo-sphenoidal  abscess  is 
about  three  times  as  common  as  cerebellar,  accoi'ding  to  Barker.  He  also 
believes  that  abscess  in  the  brain  is  much  rarer  than  meningeal  or  subdural 
suppuration. 

Not  very  long  ago  we  had  under  the  care  of  our  colleague  Dr.  Hutton  and 
ourselves,  a  boy  eleven  years  old,  suffering  from  double  otitis  after  small- 
pox. On  admission  there  was  discharge  from  both  ears,  with  pain  in  the 
left,  and  in  the  left  temple.  Shortly  after  entering  the  hospital  he  had 
a  succession  of  rigors.  The  ears  were  full  of  thick  discharge,  and  each 
contained  a  small  polypus.     The  ears  were  cleaned  out,  the  polypoid  granu- 

1  Vide  Hilton's  Rest  and  Pain. 

2  Barker  gives  i  in.  above  and  \  in.  behind  the  centre  of  the  bony  meatus  for  sub- 
dural abscess  over  the  roof  of  the  tympanum,  and  \  in.  directly  behind  the  meatus  for  sulj- 
dural  abscess  in  the  groove  of  the  lateral  sinus.  By  enlarging  the  opening  upwards  and 
backwards,  and  then  puncturing  the  dura  mater,  avoiding  the  lateral  sinus,  any  abscess 
in  the  brain  would  probably  be  reached. 


Intxrcrajital  Abscess  763 

lations  removed,  and  the  acute  symptoms  disappeared.  There  was  no 
mastoid  trouble.  A  week  later  the  boy  became  drowsy,  with  a  subnormal 
temperature  ;  there  was  no  paralysis,  no  spasm,  except  possibly  of  the 
muscles  of  the  left  side  of  the  face,  but  this  was  probably  rather  paresis  of 
the  right  side.  Slight  cloudiness  of  the  left  optic  disc  was  found  ;  there  was 
no  apparent  tenderness.  The  next  day  a  circle  of  bone  was  removed  from 
above  and  behind  the  meatus,  the  dura  mater  opened,  and  the  brain  explored 
systematically,  but  no  abscess  was  found  in  the  temporo-sphenoidal  region. 
A  second  flap  of  skin  was  then  turned  upwards  from  the  occiput,  and  a 
small  aperture  made  in  the  skull  ;  a  trocar  was  then  passed  into  the  cere- 
bellum, and  offensive  pus  escaped  ;  the  cannula  was  left  in,  but  the  boy  died, 
apparently  of  shock,  six  hours  later.  From  examination  of  the  head  we  should 
advise  in  such  cases  the  removal  of  a  circle  of  bone  immediately  above  the 
external  auditory  meatus,  at  a  distance  from  it  varying  from  h  in.  to  i  in., 
according  to  age  ;  the  dura  mater  should  then  be  stripped  back  until  the 
roof  of  the  tympanum  is  exposed,  and  any  pus  lying  there  evacuated. 
Next,  the  dura  mater  should  be  incised  and  the  brain  explored,  first  directly 
inwards,  in  the  posterior  part  of  the  temporo-sphenoidal  lobe,  and,  failing 
this,  backwards,  inwards,  and  downwards,  and  finally  forwards.  Either  a 
temporo-sphenoidal  or  cerebellar  abscess  would  probably  be  thus  reached. 
If,  however,  the  symptoms  are  fairly  definite  and  no  abscess  is  found  in  this 
wa)',  the  skull  should  be  opened  midway  between  the  superior  and  inferior 
curved  lines  of  the  occipital  bone,  and  the  cerebellum  explored.  It  is 
readily  reached  in  this  position. 

It  should  be  remembered  that  a  cerebral  abscess  maybe  latent — i.e.  may 
exist  and  give  rise  to  few  or  almost  no  symptoms — and  yet  may  cause  sudden 
death,  probably  often  by  rupturing  into  the  lateral  ventricle. 

In  the  above  case  there  were  no  definite  symptoms  to  point  to  cerebellar 
rather  than  to  temporo-sphenoidal  abscess,  and  it  was  only,  failing  the 
latter,  that,  feeling  strongly  that  an  abscess  existed  somewhere,  we  sought 
it  in  the  cerebellum.     {Vide  also  Cerebral  Abscess.) 

In  cases  of  tuberculous  otitis  we  have  been  in  the  habit  of  freely  scraping 
out  the  middle  ear  with  a  Volkmann's  spoon,  removing  all  cheesy  bone  and 
granulation  tissue  with  or  without  a  mastoid  incision,  according  to  the  extent 
of  the  disease.  The  scraping  should  be  thorough,  and  should  be  repeated  if 
necessary. 

Where  symptoms  of  septic  absorption  and  thrombosis  of  the  lateral  sinus 
and  internal  jugular  vein  exist,  the  vein  should  be  exposed  and  ligatured, 
and  then  together  with  the  sinus  laid  open  and  cleaned  out.  Similar  con- 
stitutional symptoms  with  orbital  swelling  and  proptosis  would  indicate 
thrombosis  of  the  cavernous  sinus,  which  occasionally  occurs,  and  might 
possibly  be  reached  by  operation  through  the  orbit,  though  we  are  not  aware 
that  this  has  been  hitherto  attempted. 

Note. — In  examining  the  tympanic  C3y\\.y  post  mortem,  it  should  be  remembered  that 
the  presence  of  a  puriform  fluid  in  the  middle  ear  of  infants  is  common,  and  apparently 
rather  the  result  of  the  changes  that  take  place  after  the  entry  of  air  into  the  tympanic 
cavity  than  a  pathological  condition. 


764 


Tumour  Grozvth  in  Childhood 


CHAPTER   XXXVI 

TUMOUR   GROWTH   IN   CHILDHOOD 


Tumour  Growtb  in  Childhood. — As  might  be  expected  in  a  rapidly 
growing   organism,  the  connective-tissue  group  of  tumours  is  that  almost 

exclusively  met  with  in  children. 
Sarcoma,  myxoma,  enchondroma,  and 
osteoma  are  the  common  forms  of 
new  growth,  and  these  are  usually  in 
an  embryonic  and  therefore  unstable 
and  rapidly  growing  form.  Soft  (en- 
cephaloid)  carcinoma  is  occasionally 
met  with,  it  is  said,  especially  in  the 
eye,  kidney,  and  testicle  ;  but  it  is 
probably  that  most  of  the  so-called 
carcinomata  are  really  sarcomata.^ 

Sarcomata  are  not  rare  in  chil- 
dren ;  they  are  commonly  of  the  small 
round-celled  or  mixed  varieties,  are 
most  often  seen  as  periosteal  gi'owths, 
and  often  follow  injuries.  They  are 
met  with  in  connection  with  the  jaws, 
the  skull,  and  the  long  bones,  most 
commonly  grow  rapidly,  early  become 
generalised,  and  are  speedily  fatal ; 
we  have  met  with  rapidly  growing 
sarcoma  as  a  sequel  of  acute  peri- 
ostitis. 

The    eye "    and   the  skin    are  not 

rarely  the  seat  of  sarcoma  ;  we  have 

seen  a  melanotic  spindle-celled  growth 

in  the  skin  of  the  dorsum   of  the   foot.     The   kidney   is    occasionally  the 

subject    of   congenital    sarcoma    {vide    Chapter    on    Diseases    of    the 

Kidney). 

^  These  are  also  common  sites  for  sarcomata  in  childhood. 

2  As  in  the  following  case,  figured  above  (fig.  191)  : 

Sarcoma  of  Eye  and  Jaw,  ^fc. — Walter  W. ,  aged  i  year  7  months  ;  admitted  July  23, 
1884.  At  birth,  in  the  left  eye  it  was  noticed  that  the  pupil  was  white  ;  three  months  ago 
the  eye  began  to  swell ;  three  weeks  ago  the  right  half  of  the  lower  jaw  began  to  enlarge 


Fig.  igi. — Sarcoma  of  the  Lower  Jaw  and 
Eyeball  in  a  child  aged  19  months. 


Neuroma  of  Posterior   Tibial  Nerve 


765 


Where  sarcomata  occur  in  the  hmbs,  early  amputation  is  the  only  treat- 
ment ;  in  the  case  of  renal  growths  the  balance  of  evidence  is  against  any 
operation.  Testicular  tumours  should  be  removed  as  soon  as  they  are 
recognised,  and  growths  in  other  situations  must  be  treated  as  the  individual 
case  may  require. 

We  have  met  with  a  Neuroma  only  once  in  a  child,  and  the  case  is  of 
sufficient  interest  to  be  worth  recording  in  detail. 

Neuroma  of  Posterior  Tibial  Xcrvc. — Alice  M.,  age  11  years  ;  admitted  May  9,  1885. 
Healthy  girl.  Three  years  ago  first  complained  of  pain  in  the  right  ankle  and  walked 
with  a  limp.  Has  been  getting  worte 
lately,  and  the  ankle  has  become  more 
tender.  On  admission  there  is  much 
tenderness  along  the  inner  side  of  the 
ankle,  extending  for  about  45  inches 
up  the  leg.  There  is  swelling  and 
some  heat  over  the  painful  area,  which 
seemed  to  correspond  to  the  tendons 
of  the  tibialis  posticus  and  flexor  longus 
digitorum.  The  case  was  thought  t(j 
be  one  of  tenosynovitis,  and  the  child 
was  sent  out  in  a  plaster-of- Paris  splint 
on  May  20.  Re-admitted  November  5. 
Condition  unaltered  ;  much  pain  and 
tenderness.  November  23,  the  limb 
was  rendered  bloodless  and  an  incision 
made  over  the  swelling  in  its  whole 
extent,  when  a  firm,  pale,  lobulated 
tumour  was  found  connected  with  the 
posterior  tibial  nerve  ;  the  growth  was 
encapsuled  and  turned  out  fairly  freely  ; 
it  reached  from  the  middle  of  the  leg 
to  nearly  the  middle  of  the  inner  side 
of  the  foot,  and  was  about  the  size  of 
two  average  fingers.  The  nerve  was 
inextricably  involved  and  ran  through 
it.  The  whole  tumour  and  the  nerve 
were  removed,  about  5  inches  of  the 
latter  being  taken  away.  No  large 
vessel  was  injured,  but  there  was 
troublesome  bleeding  from  some  small 
ones.  She  did  not  bear  the  operation 
well.  For  some  days  she  had  hyper- 
nssthesia  of  the  opposite  limb.     The 

wound  healed  well,  but  somewhat  slowly.  On  December  2  it  was  noticed  that  ankle- 
clonus  was  well  marked.  On  the  13th  the  whole  sole  of  the  foot  nearly  to  the  root  of  the 
toes  was  completely  anesthetic,  as  well  as  almost  the  whole  of  the  plantar  surface  of  the 


Fig.  192. 


-Enchondroma  of  Cervical  Spine  and 
Fingers. 


painlessly  and  to  grow  rapidly  in  size.  No  cause  known.  On  admission,  well  nourished. 
The  left  eyeball  was  enlarged  and  protruded  ;  it  was  irregular  in  shape  and  reddened  ; 
the  cornea  was  vascular.  The  lower  part  of  the  right  side  of  face  much  enlarged  ;  large 
veins  on  the  surface,  which  was  nodulated  ;  swelling  involved  whole  thickness  of  hori- 
;zontaI  ramus  of  jaw,  projecting  outwards  and  into  mouth,  which  could  not  be  closed. 
Teeth  displaced  and  loose;  no  ulceration;  no  disease  elsewhere.  August  i,  swelling 
increasing  rapidly,  not  much  pain,  losing  flesh.  Discharged  August  12,  and  died  at  home 
a  few  weeks  later. 


766 


Tuinoiw  Grozuth  in   Childhood 


little  toe.  The  sides  of  the  foot,  the  ball  of  the  great  toe,  and  to  a  less  extent  the  balls  of 
the  second,  third,  and  fourth  toes,  together  with  the  whole  of  their  plantar  surface,  were 
partially  anaesthetic.  Sensation  elsewhere  normal.  The  calf  muscles  somewhat  wasted. 
In  January  1886  she  was  practically  as  on  discharge,  but  could  walk  a  little  and  move  the 
foot  freely  without  pain.  Nutrition  of  foot  good.  Microscopically  the  tumour  was  a 
myxo-fibroma.  Nerves  could  be  traced  for  some  distance  in  it  and  then  became 
degenerated  and  lost.  March  23,  1888,  quite  well  ;  no  return  of  sensation  ;  foot  warm  ; 
arch  good  ;  walks  well ;  no  pain  or  tenderness. 

Of  the  more  innocent  growths  the  Encliondroinata  are  the  most  common  ; 
they  are  usuall)'  multiple,  occur  on  the  fingers,  and  may  be  congenital ;  they 
tend  to  grow  with  more  or  less  rapidity,  and  if  they  cause  inconvenience  may 
require  amputation  of  one  or  more  fingers.  Removal  of  the  growth  alone 
is  rarely  satisfactory,  since  it  has  been  shown  that  the  tumour  is  very  often 
central  in  origin,  as  in  the  following  instance  : 


Fig.  193. — Multiple  Enchondromata  of  the  Forefinger. 


Multiple  Enchondromata  of  the  Fingers. — Samuel  M.,  age  7  years  9  months  ;  admitted 
January  28,  1885.  When  five  months  old  swellings  were  noticed  on  the  fore  and  middle 
fingers  of  the  left  hand  ;  these  have  gradually  increased,  and  give  rise  to  much  pain  if 
injured  ;  at  other  times  they  are  painless.  On  admission,  is  a  thin,  unhealthy  boy.  Several 
cartilaginous  masses  are  growing  from  all  the  fingers  of  both  hands  ;  the  swellings  vary 
in  size  from  a  pea  to  a  small  nut,  the  largest  is  in  the  flexor  aspect  of  the  left  middle 
finger ;  this  finger  cannot  be  flexed.  The  fingers  are  large  and  distorted,  with  some 
lateral  deflection  of  the  second  and  third  fingers  of  the  right  hand.  The  worst,  the  left 
middle  finger,  was  amputated  at  the  metacarpo-phalangeal  joint,  and  the  theca  was 
stitched  up  with  catgut  (Treves).  A  section  of  the  finger  showed  a  cartilaginous  tumour, 
the  size  of  a  small  walnut,  growing  from  the  proximal  end  and  from  the  central  part  of  the 
epiphysial  line  of  the  second  phalanx.  The  flexor  tendon  was  stretched  over  the  tumour. 
A  smaller  mass  sprang  from  the  distal  end  of  the  same  phalanx.  The  wound  soon  healed. 
The  other  fingers  were  not  touched,  as  they  gave  rise  to  no  great  inconvenience.  The 
cervical  vertebrae  were  similarly  affected  [vide  fig.  192),  and  the  feet  are  now  (1899)  also 
the  seat  of  cartilaginous  outgrowths. 


Ostcoviata 


767 


Another  case  is  shown  in  fig.  193.  Osteomata  arc  usually  sessile,  com- 
posed of  cancellous  tissue  capped  with  soft  cartilaginous  or  myxochondro- 
matous  tissue  ;  they  most  frequently  spring  from  the  neighbourhood  of  an 
epiphysial  line,  may  be  multiple,  and  are  occasionally  hereditary.  These 
growths  may  require  removal  on  account  of  their  interference  with  the 
movements  of  a  joint  or  of  pain  ;  if  chiselled  or  sawn  through  at  the  base, 
they  do  not  recur.  We  have  most  often  seen  them  at  the  upper  end  of  the 
humerus,  as  in  the  case  quoted. 

Exosinsis. — Sarah  E.  T. ,  age  10  years  6  months  ;  admitted  January  g,  1884.     Timiour 
first  noticed  six  weeks  aofo  ;  has  grown  shghtly  since  ;  no  cause  known.     On  admission 
an  exostosis  as  large  as  a  good-sized  wahiut  was  found  on  the  posterior  aspect  of  the 
humerus,  2    inches   below   the    acro- 
mion ;     the    swelling    was    bilobed.  _,<:?^'^^~^? 
Removed  by  chisel   antiseptically  on  .  .  ^ 
January  17;  the  surface  was  cartila- 
ginous, the  deeper  part  composed  of 
cancellous  tissue.     Wound  healed  on 
January  22. 


■  y  '/- 

Fig.  194. — Hygroma  of  the  Neck,  asso- 
ciated with  iMacroglossia.  Mr.  White- 
head's case.  The  tongue  is  protruding. 
Vide  also  Ngjsus. 

Besides  the.  growths  already  '  ^ 

mentioned,  there  is  the  large 
group  of  Cong^enital  Fibrous 
and     Cystic     Tumours  :     the    /  7 

former  may  occur  in  any  part,  /  / 

the  latter  are  said  to  be  limi- 
ted    to     the     trunk      and      head;  Fig.  195.— Congenital  .Ser^u.-,  Cyst  of  the  Back. 

we   have,  however,  removed  a 

multilocular  cystic  growth  from  the  back  of  the  thigh  in  a  child.^  Cystic 
hygroma  of  the  axilla  is  not  very  uncommon  ;  it  usually  extends  up  into 
the  neck.  The  cystic  tumours  may  be  divided  into  several  classes.  A 
large  proportion  are  really  cavernous  lymphangiomata  (lymph  nasvi)  ;  such 
are  hygroma,  hydrocele  of  the  neck  (a  unilocular  hygroma),  the  tumour 
mentioned  above  as  removed  from  the  thigh,  and  many  others.  In  the 
second  group  are  those  cystic  tumours  resulting  from  degeneration  of  a  blood 
nsevus  ;  in  these  the  fluid  may  be  clear,  or  more  or  less  stained  by  admixture 
of  blood  pigment.  The  third  group  includes  cystic  formations  by  degenera- 
1  Morgan  has  recorded  a  hygroma  of  the  thigh  in  the  CUji.  Soc.  Trans.  1884. 


76?, 


Tumour  Grozvth  in   Childhood 


tion  in  fibrous  or  teratomatous  growths  ;  and  the  last  includes  dermoid  cysts, 
the  result  of  involuted  or  'dissociated'  blastoderm.' 

These  '  dermoid'  cysts  may  be  met  with  in  the  course  of  any  of  the  lines 
of  union  of  the  embryo,  e.g.  along  the  median  ventral  and  dorsal  lines  of  the 
trunk,  in  the  face,  head,  palate,  neck,  &c.  These  cysts  are  due  to  closing 
in  of  the  tissues  over  a  portion  of  epiblast ;  hence  the  cyst  wall  is  com- 
posed of  more  or  less  perfectly  formed  skin,  with  hairs,  sebaceous  glands, 

&c.  ;  lying  in  the  cavity  of  the  cyst 
will  be  found  sebaceous  matter 
and  hairs,  and  epidermic  scales. 
Perhaps  the  commonest  sites  for 
these  tumours  are  the  outer  angle 
of  the  orbit  (orbital  fissure),  the 
inner  angle  (lachrymal  fissure),  and 
the  median  ventral  line.  In  the 
auricle  they  may  result  from  inclu- 
sion of  skin  between  the  tubercles 
by  fusion  of  which  the  auricle  is 
formed.  They  are  sometimes  met 
with  in  the  middle  line  of  the  nose, 
and  cause  much  disfigurement  by 
the  growth  of  hair  from  their  in- 
terior ;  in  this  position  they  must 
be  due,  as  pointed  out  by  Bland 
Sutton,  to  some  irregular  laying 
down  of  the  skin,  since  there  is  no 
line  of  fusion  in  the  development 
of  the  embryo  at  this  spot.  Pro- 
bably the  growth  of  the  nasal 
bones  and  lateral  cartilages  causes 
some  inversion  of  the  skin.  The  growth- of  hair  seen  upon  the  nose  in  later 
life  suggests  a  possible  similarity  between  the  two  conditions. 

Dermoid  cysts  differ  from  acquired  sebaceous  cysts  in  that  they  are  con- 
genital, that  they  lie  deeper  than  the  ordinary  wen,  being  in  the  subcutaneous 
or  even  in  the  submuscular  tissues,  and  in  the  case  of  the  skull  they  may 
cause  partial  or  complete  absorption  of  the  underlying  bone.  The  skin  over 
a  dermoid  cyst  is  usually  of  natural  appearance  and  of  normal  thickness,  not 
thinned  and  showing  dilated  capillaries,  as  is  often  the  case  in  sebaceous 
cysts.  In  sebaceous  cysts  the  aperture  of  the  gland  is  often  visible  as  a  black 
speck  :  no  such  mark  is  seen  in  a  dermoid  tumour.  Should  the  dermoid 
cysts  grow  and  become  unsightly,  they  should  be  excised,  but  it  must  be  re- 
membered that  their  removal  may  be  dangerous  on  account  of  their  deep 
relations,  and  that,  as  they  are  lined  with  more  or  less  perfect  skin,  complete 
removal  is  required,  and  it  is  not  sufficient  to  lay  open  and  scrape  the  cyst 
wall. 

1  The  relations  of  congenital  '  displacements '  to  subsequent  tumour  growth  cannot,  of 
course,  be  discussed  here  ;  probably  only  a  small  number  of  cases  are  to  be  thus  accounted 
for  [vide  Cohnheim  ;  also  Eve's  Lectures  at  the  Roy.  Coll.  of  Surgeons,  1883,  and  Bland 
Sutton's  Lectures  on  Evolution  in  Pathology,  Brit.  Med.  Jour.  1889). 


Fig.  ic 


-Dermoid  Cyst  of  Orbit. 


Dermoid  Tuinoiirs 


769 


Mr.  Bland  Sutton,  in  his  lectures  delivered  at  tiic  Royal  College  of  Surgeons,  classifies 
dermoid  tumours  as  (i)  Sequestration  dermoids;  (2)  Tubular  dermoids;  (3)  Ovarian 
dermoids. 

The  first  occur  usually  in  the  lines  of  union  of  the  embryo,  or  are  a  result  of  accident ; 
a  sort  of  subcutaneous  grafting  of  dermal  tissue. 

Tubulo-dermoids  arise  in  connection  with  '  obsolete  canals  '  '  associated  with  the  primi- 
tive alimentary  canal'  They  may  exist  as  'dermoid  cysts,'  'dermoid  tumours,'  or  as 
'thyroid  dermoids,'  or  'congenital  adenomata.'  The  first  two  varieties  do  not  differ 
from  sequestration  dermoids,  except  that  they  are  more  complex.  Mr.  Sutton  calls  them 
thjToid  dermoids  because  of  their  histological  resemblance  to  the  thyroid  body.  '  They 
present  easily  recognisable  characters:   (i)  they  arise  in   obsolete   sections  of  the  gut; 


Fig.  197. — '  Dermoid  '  Cyst  of  the  Forehead.     Mr.  Hardie's  case. 

(2)  resemble  structurally  the  thyroid  body;  (3)  are  frequently  associated  with  striped  or 
unstriped  muscle  fibre;  and  (4)  are  usually  congenital.'  'The  most  typical  specimens 
occur  in  the  neighbourhood  of  the  coccyx,  in  the  tongue,  and  in  the  neck.'  1 

After  further  details,  for  which  we  must  refer  to  the  '  British  Medical  Journal,'  March  2, 
1889,  whence  the  above  extracts  are  taken,  A'Ir.  Sutton  concludes  his  most  interesting- 
account  of  these  curious  growths  by  remarking  :  '  It  is  an  interesting  fact  that  the  six 
obsolete  canals  existing  in  the  embryo  of  a  mammal,  namely,  the  infundibulum,  neuren- 
teric  passage,  post-anal  gut,  cranio-pharyngeal  canal,  thyreo-lingual  duct,  and  the  duct  of 
the  yolk  sac,  should  all  have  direct  relation  with  the  alimentary  canal,  and  each  be  directh' 
associated  with  dermoids,  often  of  considerable  complexity,  and  with  a  peculiar  form  of 
tumour,  identical  in  structure  with  the  thyroid  body.'  Some  time  ago  we  met  with  a 
case  of  an  infant,  a  twin  three  days  old,  who  was  the  subject  of  a  large  unilocular  cystic 


'    Vide  also  Marshall,  Jo/ir.  Anat.  and  Pliys.  vol.  xxvi. 


.S  D 


770 


Tumour  Growth  in  Childhood 


tumour  growing  from  beneath  the  coccyx,  and  forming  a  somewhat  pendulous  mass 
hanging  from  the  perinEeum.  The  cyst  was  thin-walled,  and  about  the  size  of  the  child's 
head.  A  day  or  two  after  admission  the  cyst  burst,  and  gave  exit  to  about  half  a  pint  of 
clear  yellow  fluid — practically  serum.  We  removed  the  collapsed  cyst  by  incision,  and 
found  a  fine  channel  running  up  into  the  pelvis  for  about  \h  inch.  The  child  did  well, 
and  was  sent  out  with  the  wound  nearly  healed  in  March  1889.  Sections  of  the  wall  of 
the  cyst  showed  a  distinctly  villous  lining,  with  a  single  layer  of  somewhat  indistinct 
roundish  cells. 

Vide  also  chapter  on  Malformation  of  the  Digestive  Apparatus. 

An  important  group  of  tumours  in  childhood  is  formed  by  the  fatty 
groivths  often  met  with.  There  may  be  simple  general  obesity  or  hyper- 
trophy of  fat,  a  condition  often  met  with  in  our  experience  in  association 
with  malformations  such  as  club-foot,  spina  bifida,  giant  foot,  &c.^     Jacobi,^ 


Fig.  198. — Dermoid  Cyst  in  the  Lachrymal  Fissure.     A  tooth  is  seen 
growing  at  the  upper  part  of  the  tumour.     Prof.  Young's  case. 


who  has  collected  many  of  the  cases  on  record  of  hypertrophy  of  the 
extremities,  attributes  the  condition  to  intra-uterine  venous  congestion  ^  in 
early  fcetal  life  ;  if,  however,  this  occurs  before  the  first  half  of  intra-uterine 
life,  during  which  no  fat  is  said  to  be  formed,  myxomatous  tissue  is  developed  ; 
if  in  the  later  stages,  fatty  tissue. 

Lipoma  may  occur  in  any  part  of  the  body  ;  it  is,  however,  rarely  met 
with  in  the  head.  Congenital  lipomata  are  often  not  encapsuled  ;  they  are 
sometimes  associated  with  naevus,  as  in  fig.  85  (nsvus  lipomatodes),  or,  as 

1  The  cervical  fatty  growths  met  with  in  cretins  are  also  noteworthy  in  this  connection. 

2  Archives  of  Pediatrics,  February  1884.  Jacobi's  list  contains  obviously  very  different 
pathological  conditions.     Also  Bland  Sutton,  Brit.  Med.  Jour.  vol.  i.  1890,  p.  877. 

'"  Busey  attributes  it  to  lymph  stagnation. 


Fatty   Tumours 


771 


in  one  case  of  Jacobi's,  with  spina  bifida.  Congenital  sacral  tumours  are 
sometimes  mainly  fatty,  as  in  one  or  two  of  our  own  cases  ;  but  these,  and 
indeed  congenital  lipomata  elsewhere,  are  by  no  means  always  pure  fatty 


Fig.  199. — Congenital  Myxo-Lipoma  of  the  Breast.     The  tumour  was  removed,  and  the 
child  did  well.     We  have  lately  seen  a  second  similar  case. 


grovvths  ;  fibrous,  bony,  or  cartilaginous  material  may  be  mixed  up  with  the 

fat,  as  well  as  ntevus,  muscular  tissue,^  &c.  ;  these  more  complex  tumours 

belong   to   the   teratomatous  class  rather  than  to  the    ordinary   lipomata. 

When  occurring  in  the  foot  congenital 

lipoma  forms  one  of  the  varieties  of 

so-called  '  giant  foot,'  of  which  fig.  200 

is  a  specimen  ;  in  some  of  these  cases 

the  growth  is  encapsuled  ;  in  others  it 

is  diffuse,  and  after  incomplete  removal 

it  shows  a  tendency  to  recurrence.     In 

these  cases  of  giant  limb,  which  are 

usually  unilateral,  the  rate  of  growth 

is  variable,  and  all  the  constituents  of 

the  limb  are  overgrown  in  some  cases, 

while  in  others  the  bones  are  enlarged, 

the  vessels,  muscles,  and  nerves  being 

normal.'-   (See  also  chapter  on  N^vus 

for  an  account  of  the  lymphatic  form 

of  'giant  foot.') 

Fatty   tumours    of    doubtful    con- 
genital origin  are  sometimes  met  with,  and  may  be  the  seat  of  myxomatous 
change,  as  in  the  appended  case. 


Fig.  200. — Giant  Foot  (the  Fatty  Variety),  the 
growth  affecting  mainly  the  toes,  but  also  to 
some  extent  the  sole  of  the  foot. 


1  Vide  Butlin,  St.  Earth's  Reports,  1877. 

2  Vide  Anderson,  St.  Thomas  s  Hospital  Reports,  1881  ;  Barwell,  Clin.  Sac,  Trans. 
1884;  Blackader,  Arch,  of  Pcediatrics,  Oct.  1884;  Esmarch  and  Kulenkampff,  Die 
elephantiastischeri  Formen,  Hamburg  1885. 

3  D  2 


772 


Tumour  Growth  in   Childhood 


Case. — Congenital  (?)  Myxo-lipoma  of  Thigh. — William  M.,  age  2  years  ;  admitted 
November  2,  1885.  Child  began  to  walk  last  January,  but  was  weak  and  soon  tired  ; 
had  a  severe  fall  at  that  time.  Four  months  ago  a  swelling  was  first  noticed  at  the  back 
of  the  left  thigh  ;  it  has  gradually  increased  in  size,  but  has  never  been  painful.  Has 
been  wearing  splints  for  ricket}'  deformity  lately.  No  sores  about  the  legs.  On  admission, 
a  very  rickety  child.  In  the  middle  of  the  back  of  the  left  thigh  is  a  soft  movable  swel- 
ling, not  tender,  not  well  defined,  and  indistinctly  fluctuating  (?).  The  swelling  is  about 
the  size  of  a  large  walnut  or  larger.  November  5,  an  incision  was  made  over  the  swelling 
between  the  hamstrings  ;  it  was  found  to  project  on  the  inner  side  of  the  great  sciatic 
nerve,  and  was,  with  some  dissection,  shelled  out  from  its  deeper  attachments  to  the 
superficial  layer  of  periosteum  ;  it  extended  from  the  upper  border  of  the  popliteal  space 
upwards  to  about  2\  inches.  The  whole  growth  was  removed  ;  it  was  fairly  well  en- 
capsuled,  soft,  and  gelatinous.  Microscopically  it  proved  to  be  a  myxo-lipoma.  On 
November  16  all  stitches  were  removed  and  the  wound  was  almost  healed.     Sent  home. 


Fig.  201. — Congenital  Cystic  Tumour  of  the  Groin.     Mr.  Hardie's  case. 

Compound  Congenital  Tumours  occur  most  frequently  about  the  sacral 
and  lumbar  regions  ;  their  origin  is  obscure,  and  has  been  accounted  for  on 
the  view  of  included  foetation,  gemmation,  or  inclusion  of  a  portion  of  the 
outer  layer  of  blastoderm,  at  the  time  of  closure  of  the  dorsal  laminse.^  The 
tumours  are  often  cystic,  and  may  contain  masses  of  fat,  cartilage,  bone,  and 
skin  elements.     They  vary  in  size,  and  may  attain  great  dimensions  ;  their 


^  Mr.  Bland  Sutton  divided  these  tumours  into  four  classes  :  i.  Sacral  spina  bifida  ; 
2.  Tumours  originating  in  the  post-anal  gut ;  3.  C3'stic  tumours  originating  in  the 
neurenteric  canal ;  4.  Parasitic  foetuses. — Erasmus  Wilson's  Lectures,  Brit.  Med.  Jour. 
P'ebruary  12,  1887. 


Congenital  Sacral   'riuiionrs 


771> 


rate  of  growth  usually  corresponds  v/ith  that  of  the  child  ;  they  may  become 
ulcerated  fi'om  irritation.  Such  tumours  give  rise  to  trouble  by  their  weight 
and  bulk,  and  their  interference  with  movement' 

Cask. — Congenital  Sacral  Tumour, — Elizth.  Ann  T.,  age  4 years  ;  admitted  February 
2,  1885.  Always  a  delicate  child  ;  more  so  since  an  attack  of  scarlet  fever  at  two  years. 
The  tumour  has  gradually  increased  to  twice  the  size  it  was  at  birth.  She  has  had  no  fits  ; 
vomits  frequently  after  meals  ;  cannot  retain  her  urine,  but  has  no  incontinence  of  faeces  ; 
sleeps  badly  and  complains  of  abdo- 
minal pain.  On  admission,  a  delicate 
child.  Over  the  lower  lumbar  and 
upper  sacral  vertebrae  is  a  soft,  pulpy 
tumour,  about  the  size  of  a  small 
orange ;  the  skin  is  natural  over  it ; 
there  is  no  tenderness  on  pressure,  and 
the  swelling  is  not  fluctuating.  There 
is  loss  of  power  in  both  legs  ;  the  child 
can  draw  them  up  in  bed,  but  cannot 
support  herself  upon  them.  February 
13,  the  tumour  was  explored  with  a 
needle,  but  no  fluid  was  found  ;  a 
straight  incision  was  then  made  over 
the  swelling  and  the  skin  reflected, 
exposing  a  mass  of  fat.  On  dissecting 
this  carefully  away  a  small  tumour  the 
size  of  a  filbert  was  exposed ;  this 
evidently  contained  fluid  and  could  be 
seen  to  pulsate ;  it  clearly  was  con- 
nected with  the  theca ;  this  was  left 
uninjured,  and  the  fatty  mass  dissected 
away  from  it.  The  wound  was  drained 
and  sutured ;  operation  antiseptic. 
On  making  a  section  of  the  growth  a 
small  nodule  of  cartilage  was  found 
in  its  centre.  February  14,  dressed ; 
about  half  an  ounce  of  blood-stained 
serum  escaped ;  child  vomited  once, 
otherwise  well. ;  no  convulsions  or 
pain  ;  tube  removed.  15th,  was  sick 
twice  yesterday,  and  awoke  several 
times  in  the  night,  screaming.  i6th,  sick 
again  yesterday  ;  no  more  screaming  ; 
lies  very  quiet.  i8th,  dressed  ;  aquantity 
of  serum  collected  beneath  the  skin,  so 
tube  was  put  in  again  ;  has  been  very 
irritable  for  last  two  days  ;  sick  once  in 
the  night ;  slept  well ;  ice  to  head  and  spine ;  no  squint  or  convulsions  ;  temperature 
normal.  19th,  is  a  little  better.  She  became  steadily  worse,  and  died  on  the  21st 
with  evidence  of  meningitis.     The  highest  temperature  was  99 '2°. 

Post-mortem.— On  removing  the  brain  an  excess  of  fluid  escaped  ;  the  surface  of  the 
brain  was  congested,  but  otherwise  natural  ;  there  was  some  matting  together  along  the 
Sylvian  fissure,  but  no  other  abnormal  appearance.  Spitial  cord,  excess  of  fluid  and  much 
congestion  at  the  seat  of  the  tumour  and  for  four  inches  above  it.     The  cord  ended  in  a 

I  Vide  Clin.  Led.  by  James  Hardie,  F.R.C.S.,  Lancet,  May  2,  1885.  Into  the  subject 
of  teratology  it  is  impossible  to  enter  here,  but  the  reader  may  refer,  among  other  works, 
to  Forster's  Missbildungen  dcs  Meiischen  and  Ballantyne's  Antenatal  Pathology. 


Fig.  202. — Congenital  Sacral  Tumour  with  Talipes. 


774 


Tumour  Grozvth  in   Childhood 


fibrous  expansion  which  spread  out  over  the  tumour.  Small  portions  of  the  tumour 
extended  downwards  into  the  sacrum.  The  laminae  were  imperfect  at  the  seat  of  the 
tumour ;  the  central  canal  of  the  cord  was  dilated  below  the  mid-dorsal  region,  and  the 
left  cornu  of  grey  matter  had  disappeared,  leaving  a  hollow  space.  This  was  evidently  a 
combination  of  spina  bifida,  syringo-mj^elia,  and  a  congenital  tumour  of  cartilage  and 
fat.  The  operation  was  undertaken  with  the  view  of  possibl}'  relieving  the  cord  of  pres- 
sure and  so  removing  the  paraplegia,  but  there  is  much  risk  of  meningitis  in  these  cases. 

As  these  gfowths  are  usually  median  in  position  or  nearly  so,  they 
simulate  spina  bifida  :  hence  they  have  been  called  '  false  spina  bifida '  {vide 
p.  568) ;  they  may  have  attachments  within  the  spinal  canal  or  pelvis. 

Any  congenital  tumour  of  the  vault  of  the  skull  or  over  the  spine  should 
be  looked  upon  with  suspicion,  as  likely  to  have  intimate  relations  with  the 
cranial  or  spinal  cavities.  The  appearance  of  the  skin,  the  mobility  of  the 
tumour,  its  reducibility,  and  the  effects  of  pressure,  &c.,  are  the  points  to  be 
looked  to  {vide  Chap.  XXVI).  It  is  sometimes  impossible  to  diagnose 
nsvus  from  other  soft  growths  ;  the  presence  of 
cutaneous  stains  or  of  nsevi  elsewhere,  the  effects  of 
straining  or  crying,  the  possibility  of  partly  emptying 
the  tumour,  and  its  peculiar  spongy  feel,  must  be 
taken  into  account  (vide  Chap.  XX).  We  have 
recently  (1899)  had  under  our  care  a  child  of  a  few 
months  old  with  a  large  cystic  abdominal  tumour.  On 
opening  the  abdomen  the  tumour  turned  out  to  be  a 
'  parasitic  foetus  '  in  the  lesser  cavity  of  the  peritoneum. 
The  tumour  was  firmly  attached  to  various  viscera  and 
the  posterior  abdominal  wall,  but  was  removed.  The 
child  died  of  shock.  The  mass  contained  skin,  bone, 
coils  of  intestine,  and  other  imperfectly  developed 
viscera. 

Treatment. — Congenital  lipomata,  if  large,  rapidly 
growing,  painful,  or  inconvenient,  should  be  excised. 
The  congenital  sacral  tumours,  unless  for  some  very 
good  reason,  should  be  left  alone — there  is  much  risk 
of  injury  to  the  spinal  contents,  as  seen  in  the  case  just  related. 

Cystic  growths  may  be  treated  by  tapping,  injection,  setons,  incision,  or 
excision  ;  none  of  these  modes  are  free  from  danger,  and  the  last  is  some- 
times impossible  from  the  extent  and  connections  of  the  mass.  In  large 
unilocular  deep-seated  cysts,  such  as  'hydrocele  of  the  neck,'  tapping, 
followed  by  injection  with  Morton's  solution  if  the  cyst  refills,  is  the  best 
plan  ;  if  suppuration  occurs,  free  incision  and  drainage  must  be  employed. 
The  multilocular  cysts  are  often  best  treated  by  setons,  small  threads 
being  inserted  and  the  process  repeated  if  necessary.  In  the  cavernous 
lymphatic  nsevi,  much  lymph  may  drain  away  if  the  growth  is  cut  into,  just 
as  bleeding  occurs  from  a  blood  nsevus,  and  there  is  much  risk  of  septic 
infection  or  exhaustion  :  hence  these  growths  should  be  removed  entire,  if 
at  all.i 

In  the  case  of  giant  foot  the  fatty  variety  has  a  tendency  to  steadily 


Fig.  203. — Section  of  Con- 
genital Sacral  Tumour. 
A  points  to  the  spinal 
canal  ;  b  to  the  body  of 
a  vertebra  ;  c  to  a  mass 
of  ossifying  cartilage  in 
the  tumour. 


1-  For  further   details  vide  T. 
Guy's  Hospital  Ecpoiis,  i860. 


Smith,  CHji.   Soc.    Tra?is.   1880,  vol.  xiii.,  and  Birkett, 


Congenital  Sacral  Tumours  775 

grow,  and  though  pressure  may  slightly  retard  it,  we  have  not  found  it  suc- 
ceed as  a  means  of  treatment.  Ligature  of  the  anterior  and  posterior  tibial 
arteries  in  the  following  case  gave  a  good  result  for  a  time,  but  after  a  year 
or  two  the  growth  continued.  In  such  cases  the  choice  is  between  leaving 
the  case  alone  and  amputation  ;  the  latter  should  only  be  done  when  the 
crippling  from  the  presence  of  the  growth  is  greater  than  would  result  from 
the  mutilation. 

Case. — Pes  Gigas.  Lipamaious  Variety. — Emily  C. ,  age  9  months  ;  admitted  June  23, 
1884.  Family  history  unimportant.  At  birth  it  was  noticed  that  the  left  foot  was  dis- 
tinctly larger  than  the  right ;  since  that  time  it  has  steadily  grown  ;  there  has  been  no 
pain,  and  the  child's  health  has  been  unaffected.  [Thanks  to  the  courtesy  of  Mr.  Withers, 
of  Sale,  we  were  able  to  watch  this  case  almost  from  the  first.]  On  admission,  a  fat, 
healthy  child  ;  the  left  foot  much  enlarged,  chiefly  the  dorsum  and  inner  side  ;  toes  not 
affected  ;  skin  natural,  dimples  on  raising  it ;  at  the  outer  side  a  few  hard  nodules  can  be 
felt.     Measurements : 


At  root  of  toes 

65  in. 

.      Ri 

ght  foot 

4i 

in. 

circumference. 

At  middle  of  foot 

75  in. 

, , 

4l 

Across  heel  and  foot 

8    in. 

,, 

5^ 

Around  ankle 

7    in. 

', 

5i 

Middle  of  calf 

75  in. 

,, 

7* 

,, 

Elastic  pressure  was  fairly  tried  for  a  long  time  prior  to  admission  without  apparently 
diminishing  the  rate  of  overgrowth.  The  temperature  of  the  two  limbs  did  not  apparently 
differ,  and  the  child  could  kick  the  foot  about,  though  it  did  so  clumsil)'.  On  July  2  the 
posterior  tibial  artery  was  ligatured  in  the  middle  of  the  leg  by  the  usual  method,  a 
catgut  ligature  being  employed  ;  the  vessel  was  very  small,  and  its  pulsations  feeble  ;  a 
drainage  tube  was  used  ;  operation  antiseptic  ;  all  went  on  well.  On  the  nth  the 
measurements  were  as  before,  except  the  one  at  the  root  of  the  toes,  which  was  i  in. 
less  ;  wound  almost  healed.  July  12,  the  anterior  tibial  artery  was  ligatured  doubly,  and 
divided  between  the  ligatures ;  the  veins  were  included  in  the  ligatures.  21st,  first 
dressing,  wound  all  healed;  no  drainage  was  used;  measurements  as  on  nth,  e.xcept 
middle  of  foot  \  in.  less.  28,  Martin's  bandage  applied  again  ;  the  warmth  of  the  foot 
seems  in  no  way  interfered  with.  August  4,  measurements  :  Root  of  toes,  6g-  in.  ;  middle 
of  foot,  75  in.' ;  across  heel  and  foot,  8  in.  ;  around  ankle,  j^  in.  ;  middle  of  calf,  j\  in. 
February  1885,  the  foot  is  getting  smaller  in  all  dimensions.  Subsequently  the  growth 
remained  stationar}'  for  a  while  and  then  increased. 

Xiymptaoma  (liyiupbadenoina,  Xiymphosarcoiua)  is  sometimes  met  with 
in  the  shape  of  large  masses  of  glands  in  the  neck  (fig.  204)  or  elsewhere,^ 
which  slowly  grow  and  give  trouble  from  their  size,  unsightliness,  and  pressure 
effects  {vide  Hodgkin's  Disease),  as  well  as  ultimately  cause  death. 

Removal  of  such  masses  of  glands  is  usually  of  only  temporary  value  ;  it 
is  seldom  that  all  can  be  got  away,  and  recurrence  often  takes  place  in  a  short 
time.  Section  of  such  a  tumour  shows  a  pinkish-grey  lymphoid  tissue  with 
no  caseous  foci. 

The  following  was  a  characteristic  case  : 

Case. — Lymphoma  of  Neck. — John  T. ,  age  12  years  4  months  ;  admitted  November 
10,  1882.  Family  history  good,  except  that  the  mo  ther  had  abscesses  beneath  the  jaw  whilst 
pregnant  with  this  child  ;  boy  himself  never  very  hearty,  but  had  fair  health  ;  four  years 
ago  a^swelling  appeared  beneath  the  lower  jaw  on  the  left  side  ;  this  grew  slowly  till  the 
last   three  months — since  then  it  has  increased  rapidly ;  for  three  weeks  has  had  pain. 

1  Cystic  lymphomata  are  sometimes  met  with,  and  these  growths  have  been  found  in 
the  rectum,  among  other  places. 


77^ 


Tumoiir  Growth  in   Childhood 


On  admission,  in  the  left  posterior  triangle  is  a  large  globular  tumour  consisting  of  lobu- 
lated  lymphomatous  masses ;  the  swelling  extends  from  i  inch  below  the  jaw  to  \  inch 
below  the  clavicle,  which  it  overhangs  ;  it  is  5!  inches  in  transverse  diameter  ;  some  of  it 
projects  beneath  the  trapezius,  and  outlying  masses  reach  nearly  to  the  middle  line  of  the 
neck  ;  the  skin  is  movable  over  it,  and  it  is  not  fixed  to  the  vertebra  ;  no  marked  glandu- 
lar enlargement  elsewhere,  though  a  few  slightly  enlarged  glands  can  be  felt  in  the  left 
groin  ;  some  dulness  over  apex  of  left  lung ;  left  pupil  slightly  smaller  and  less  sensitive 
than  right.  On  November  16  the  gland  masses  were  removed,  weighing  8  oz.  ;  most  of 
the  glands  shelled  out  easily,  some  were  adherent  ;  the  external  jugular  vein  was  tied  and 
divided ;  at  times  when  traction  was  made  upon  the  carotid  sheath  during  the  operation 
the  pulse  was  much  accelerated  ;  the  carotid  sheath  and  cervical  transverse  processes  were 
exposed.     He  bore  the  operation  well  and  lost  little  blood.     Operation  antiseptic,  with 

sponge     pressure ;      recovery     uninterrupted  ; 

antiseptics  were  left  off  on  December  6,  and  he 

H\\\  \  \\^^  ^^^^  discharged  with  a  small  superficial  wound. 

\v^  VV^^^  February  1883,  the  boy  has  been  better  since 

III™  V^^^Mrl  "^^  operation,  but  new  masses  of  glands  are 

lU  W      ^M?;/  already  beginning  to  enlarge,  though  at  and 

after  the  operation  none  could  be  felt. 

Another  case  is  shown  in  fig.  204. 
It  is  not  at  all  uncommon  to  find  cases 
in  which  certain  of  the  glands  have 
broken  down  and  discharged,  while  in 
other  respects  the  conditions  resemble 
lymphoma  rather  than  tuberculosis- 
We  have  accounted  for  these  cases 
by  supposing  that  tuberculosis  and 
Hodgkin's  disease  have  co-existed.  We 
have  seen  lymphoma  also  appear  in 
a  child  the  subject  of  hip  disease. 
Variation  in  the  size  of  the  swellings, 
associated  with  fever,  but  subsiding 
without  suppuration,  is  also  often  seen. 

IMCultilocular  Cystic  Growths  of  the  Jaws  arise  from  epithelial 
ingrowths  from  the  surface  of  the  gum,  which  afterwards  become  shut  off  and 
develop  cysts  ;  they  may  be  congenital  or  occur  in  infancy.  Besides  these, 
two  other  forms  of  cyst  are  found  associated  with  the  teeth  (dentary  cysts)  : 
(i)  Cysts  originating  in  connection  with  the  tooth  follicles — follicular,  or,  it 
they  contain  teeth,  dentigerous  cysts:  (2)  Periosteal  cysts,  originating  beneath 
the  periosteum  of  the  jaw. 

Dentigerous  cysts  arise  from  mal-placed  or  mal-developed  teeth,  and  may 
occur  at  any  part  of  the  jaws  ;  they  contain  clear,  serous  or  glairy,  white  or 
coloured  fluid,  rarely  pus.  Most  often  they  are  associated  with  the  perma- 
nent, sometimes  with  the  milk  teeth.  Eggshell  crackling,  the  presence  of 
fluid,  and  suppression  of  a  tooth  are  the  common  indications  of  the  nature  of 
these  swellings.  (Eve,  'Brit.  Med.  Jour.,'  Jan.  6,  1883;  Heath,  'Lancet,' 
1887.) 

For  further  details  on  the  question  of  tumours  we  must  refer  to  the 
general  text-books. 


204. — Lj-mphoma  of  the  Neck. 


777 


CHAPTER   XXXVII 

DISEASES    OF    THE   THYROID   AND   THYMUS 

Acute  Enlargement  of  the  Thyroid. — A  slight  enlargement  with 
tenderness  of  the  thyroid  gland  is  not  uncommon,  but  any  acute  enlarge- 
ment, the  result  of  inflammation,  is  very  rare.  A  typical  case  of  this  kind  is 
recorded  by  Dr.  T.  Barlow,'  in  a  boy  of  three  years.  The  symptoms  at  first 
consisted  in  pain  in  the  neck  on  movement,  feverishness  and  slight  enlarge- 
ment of  the  thyroid  gland.  Later  the  swelling  considerably  increased  ;  the 
temperature  varied  from  ioo°  to  103°  F.  ;  there  was  some  difficulty  in 
swallowing,  but  no  marked  dyspnoea.  In  four  or  five  days  the  swelling 
began  to  subside  ;  he  finally  made  a  good  recovery. 

Chronic  Enlarg-ement.  Goitre. — Simple  or  cystic  enlargement  of  the 
thyroid  is  sometimes  met  with  in  children,  most  commonly  in  the  inhabitants 
of  certain  hilly  districts  such  as  Derbyshire  ;  it  is,  however,  met  with  in  some 
cases  among  town-bred  children,  both  with  and  without  a  family  history  of 
goitre. 

In  the  case  here  figured  half  the  gland  was  removed  ;  it  consisted  of  a 
mass  about  the  size  of  a  small  orange  ;  in  it  were  many  cysts,  the  larger  of 
which  contained  reddish-yellow  fluid.  The  child  did  perfectly  well,  but  died 
some  months  later  of  scarlet  fever  ;  the  other  half  of  the  gland  had  not 
appreciably  altered  after  the  operation. 

We  have  been  three  times  called  upon  to  perform  tracheotomy  in  young- 
people  for  urgent  dyspnoea,  the  result  of  pressure  of  an  enlarged  thyroid 
gland  ;  in  two  cases  the  patients  were  young  adults,  the  third  was  an  ill- 
developed,  idiotic  child,  in  whom  there  was  enlargement  of  the  tonsils,  with 
post-nasal  vegetations  ;  these  had  been  dealt  with  once  with  marked  im- 
provement, but  on  the  second  occasion  sudden  dyspnoea,  evidently  due  to 
pressure  of  the  enlarged  thyroid,  was  brought  on  by  an  attempt  at  examina- 
tion, and  on  administering  chloroform  the  breathing  stopped  ;  tracheotomy 
was  performed,  and  the  child  did  fairly  well  for  a  day  or  two,  but  died  of 
bronchitis  on  the  3rd  or  4th  day.  The  operation  under  such  circumstances 
may  be  of  e.xtreme  difficulty  alike  from  the  presence  of  the  large  mass  of 
gland,  from  the  engorgement  of  the  vessels,  and  from  the  altered  shape  of 
the  trachea,  which  is  compressed  laterally.  A  specially  long  tube  is  required 
to  reach  down  below  the  constricted  part  of  the  windpipe.     There  is  no 

'  '  On  a  Case  of  Acute  Enlargement  of  the  Thyroid  Gland  in  a  Child,'  by  Dr.  'J". 
Barlow,  Cliii.  Soc.  Trans,  vol.  xxi. 


778 


Diseases  of  the   Thyroid  and  Thymus 


doubt  that  in  any  case  where  attacks  of  dyspnoea,  '  thyroid  asthma,'  have 
recurred,  either  removal  of  part  of  the  gland  or  division  of  the  isthmus 
should  be  performed  in  an  interval  between  the  attacks.^  In  simple  cases 
of  goitre  the  treatment  is  the  same  as  for  adults. 

We  have  divided  the  thyroid  isthmus  in  a  young  gentleman  of  sixteen,  in 
whom  acute  attacks  of  almost  fatal  dyspnoea  had  more  than  once  occurred. 

The  trachea  was  much  flattened  late- 
rally ('scabbard  trachea').  Three  weeks 
after  operation  the  gland  had  resumed 
nearly  its  normal  size.  In  another  case 
the  operation  was  done  during  an 
attack,  and  the  patient  died  a  few 
hours  later  from  rapid  oedema  of  the 
lungs.  In  another,  part  of  the  gland 
was  removed  and  tracheotomy  per- 
formed ;  the  patient  recovered,  though 
in  cases  where  tracheotomy  is  neces- 
sary the  danger  to  life  is  much  in- 
creased. 

It  is  not  very  uncommon  to  see 
children  in  whom  the  thyroid  is 
slightly  enlarged  and  sometimes  pain- 
ful and  tender,  but  in  whom  there  is 
no  very  great  deformity  and  no  cystic 
development.  These  cases  of '  simple 
bi'onchocele '  may  be  met  with  at  any 
age,  but  are  perhaps  most  common 
about  puberty.  Under  treatment  with  iodine  or  arsenic  internally,  and 
weak  red  iodide  of  mercury  ointment,  cautiously  used,  externally,  the  gland 
usually  returns  to  its  natural  size.     Iron  is  required  if  there  is  anaemia. 

The  thyroid  gland  is  usually  absent  in  cases  of  myxoedema  or  '  sporadic 
cretinism  ; '  in  any  case  of  wasting  or  disease  of  the  thyroid  the  possibility 
of  myxoedema  must  be  borne  in  mind.     (See  p.  559.) 

Tbyiuus  Gland. — The  thymus  body  or  gland  reaches  its  greatest  size  at 
two  years  of  age,  after  which  it  dwindles,  and  by  puberty  is  in  most  cases 
reduced  to  a  mere  vestige.  At  birth  it  measures  some  2  in.  in  length  and 
perhaps  \\  in.  in  bi-eadth,  and  weighs  about  ^  oz.  At  two  years  of  age  it 
weighs  from  i^  to  2  oz.  It  is  situated  behind  the  upper  piece  of  the  sternum, 
reaching  as  low  down  as  the  fourth  costal  space  ;  it  lies  partly  on  the 
pericardium,  the  aortic  arch,  and  large  vessels. 

But  little  can  be  said  concerning  the  diseases  of  the  thymus.  Some 
authors  have  attributed  laryngismus  and  spasm  of  the  glottis  to  enlarge- 
ment of  the  thymus  and  a  consequent  pressure  on  the  nerves  or  trachea 
itself  It  is  very  doubtful  if  laryngismus  is  due  in  any  way  to  hypertrophy 
of  the  thymus,  but  cases  in  which  there  was  evident  pressure  on  the  trachea 
by  an  enlarged  thymus  have  been  recorded  by  Goodhart,  Jacobi,  and 
Baginsky.  Sudden  death  from  spasm  of  the  glottis  is  not  uncommon  during 
the  first  two  or  three  years  of  hfe,  and  this  has  in  some  cases  been  attributed 
1  Vide  Med.  Chron.  vol.  xi.  iSoo. 


Fig.  205. — Cystic  Bronchocele  in  a  Child. 


Thymus  Gland  779 

to  Ihc  presence  ot  an  enlarged  thymus  (Pott).  We  are  by  no  means  con- 
\'inced  of  this.  It  is  common  to  find  small  cysts  at  first  sight  looking  like 
abscesses  scattered  through  the  substance  of  the  thymus  ;  these  have  been 
attributed  to  syphilis.  Jacobi  has  noted  an  excessive  quantity  of  connective 
tissue  in  the  thymus  of  syphilitic  children.  He  has  also  observed  tubercu- 
losis of  the  thymus  in  cases  of  general  tuberculosis.  Demme  has  recorded 
a  case  in  which  caseous  masses  were  found.  The  thymus  when  it  becomes 
tuberculous  probably  does  so  from  contact  with  caseous  mediastinal  lymph 
glands,  as  in  case  related  at  p.  329.  In  some  recorded  instances  it  appears 
that  sarcoma  has  originated  in  the  thymus. 


780  Diseases  of  the  Skin 


CHAPTER   XXXVIII 

DISEASES    OF    THE    SKIN 

During  intra-uterine  life  the  foetus  is  surrounded  by  the  hquor  amnii,  which 
softens  and  soddens  the  cutaneous  surface.  After  birth  the  skin  is  subjected 
to  the  drying  action  of  the  air  and  the  epidermis  quickly  assumes  its  normal 
condition  ;  it  is,  however,  exceedingly  easily  fretted  and  excoriated  by 
prolonged  contact  with  the  urine  and  fasces,  and  also  by  the  hot  water  and 
soap  of  its  bath.  It  is  hardly  surprising  to  find  that  under  these  new  con- 
ditions the  skin  is  often  injured,  especially  when  we  remember  the  delicate 
nature  of  the  horny  layer  of  the  epidermis  in  the  infant.  In  consequence  01 
the  rapid  growth  which  is  taking  place,  there  is  necessarily  a  continual 
building  up  of  the  tissues  of  the  skin  to  keep  pace  with  body-growth,  and  any 
interference  with  the  infant's  digestion  or  assimilation  of  its  food  is  ex- 
ceedingly likely  to  interfere  with  the  nutrition  of  the  skin.  This  is  seen  in 
various  conditions  of  wasting  during  infancy  ;  the  skin  becomes  rough  and 
harsh,  and  the  slightest  irritation  from  the  urine  or  fasces,  or  friction  at  the 
flexures  of  the  joints,  gives  rise  to  an  erythema,  eczema,  or  to  excoriations. 

Reflex  inflammations  are  more  common  during  infancy  than  in  later  life, 
a  transference  of  inflammation  readily  taking  place  from  one  part  to  an- 
other, or  an  irritation  present  in  one  place  may  give  rise  to  an  inflammatory 
lesion  at  a  distance.  In  this  way  we  find  blotches  or  scaly  spots  around  the 
mouth  and  on  the  face  of  children  who  are  suffering  from  dyspepsia  or 
gastric  catarrh,  or  herpetic  patches  in  those  suffering  from  pneumonia  or 
bronchial  catarrh.  Urticaria  or  erythematous  blotches  may  be  the  result  of 
indigestible  food  in  the  stomach,  or  the  pressure  of  a  tooth  upon  the  gum, 
or  the  presence  of  acari  burrowing  beneath  the  skin. 

Lesions  of  the  skin  are  exceedingly  common  during  infancy  and  child- 
hood, and  we  find  eczema,  intertrigo,  urticaria,  and  dermatitis  among  the 
most  frequent  ailments  at  this  period. 


Eczema 

Eczema  during  infancy,  while  proving  amenable  to  treatment,  is  ex- 
ceedingly apt  to  relapse,  and  in  aggravated  cases  it  forms  one  of  the  most 
troublesome  complaints  with  which  the  practitioner  has  to  deal.  Probably 
most  physicians  can  call  to  mind  cases  of  eczema  in  infants  a  few  months 
old  which  have  improved  for  a  while,  then  relapsed  again  and  again,  and 


Eczema  781 

for  which  numerous  ointments,  lotions,  powders,  and  medicines  have  been 
tried  in  vain.  While  the  majority  of  these  cases  get  well  as  the  end  of  the 
first  year  is  approached,  or  only  relapse  occasionally,  in  many  cases  tlie 
eczema  continues  to  give  trouble  for  years,  or  even  for  life. 

The  causes  of  eczema  in  infants  are  various,  though,  indeed,  but  little  is 
known  for  certain  about  many  of  them.  In  some  cases,  especially  in  the 
local  eczemas,  there  are  irritants  at  work,  such  as  scabies,  pediculi,  and  the 
fretting  produced  by  napkins  constantly  wet  with  urine  or  faeces.  There 
cannot  be  a  doubt  that  there  is  a  close  relation  between  the  condition  of  the 
skin  and  the  alimentary  canal.  It  is  interesting  to  note  that  if  a  healthy 
infant  gets  an  attack  of  dyspepsia  or  diarrhcea,  its  muscles  become  flabby, 
there  is  some  wasting,  and  the  nutrition  of  the  skin  is  lowered  ;  and  now 
the  contact  of  urine  or  soiled  napkins  sets  up  an  irritative  erythema  or 
eczema,  the  irritation  of  the  soiled  napkins  being  powerless  to  excite  an 
excoriation  until  the  nutrition  of  the  skin  is  interfered  with  by  faulty 
assimilation.  One  of  the  commoner  internal  causes  of  eczema  in  infants  and 
young  children  is  an  abnormal  condition  of  the  alimentary  canal  ;  probably, 
in  seme  instances,  the  eczema  is  due  to  a  mal-assimilation  or  insufificiency 
of  food,  and  in  consequence  the  nutrition  of  the  skin  suffers.  Eczemas  are 
usually  worse  during  the  cold  east  winds  of  spring. 

In  what  class  of  children  is  eczema  the  most  common  ?  The  answer 
must  be  that  eczema  may  be  found  in  children  of  every  type  and  of  every 
social  grade.  In  the  first  place,  it  must  be  said  that  eczema  is  by  no  means 
uncommon  in  infants  and  children  who  are  apparently  in  perfect  health  ;  and 
breast-fed  infants  suffer  as  well  as  artificially-fed  infants.  We  have  fre- 
quently noted  in  hospital  that  children  admitted  for  some  other  disease,  and 
who  are  quite  free  from  any  skin  trouble,  develop  eczema  as  they  become 
fat  and  well.  In  these  cases  there  is  a  strong  presumption  that  over-feeding 
may  have  something  to  do  with  the  eczema  ;  it  is  certainly  true  that  very 
fat  children  .are  often  eczematous,  and  it  is  very  possible  that  strong, 
healthy  children  with  large  appetites  may  habitually  be  overfed,  and  the 
system  seek  relief,  as  it  were,  in  an  acute  or  chronic  discharge  from  the 
skin.  Perhaps  in  some  of  these  cases  there  is  a  history  of  eczema  in  the 
parents. 

On  the  other  hand,  as  already  remarked,  dyspeptic  children,  and  those 
who  are  badly  or  poorly  fed,  also  suffer  from  eczema. 

The  so-called  strumous  children  are  exceedingly  likely  to  suffer  from 
eczema,  especially  of  the  impetiginous  type.  The  scalp,  face,  and  backs  of  the 
ears  are  most  likely  to  be  affected  :  there  is  much  oozing  of  a  semipurulent 
fluid,  which  dries  and  forms  yellow  crusts.  The  lymphatic  glands  asso- 
ciated with  the  seat  of  the  eruption  are  apt  to  become  enlarged,  and  sub- 
cutaneous abscesses  to  form. 

It  is  a  popular  notion  that  many  of  the  eczemas  of  infancy  are  due  to 
teething,  and  that  a  chronic  eczema  is  always  worse  when  a  tooth  is  being 
cut.  Mothers  often  look  forward  to  the  last  teeth  being  cut,  as  they  believe 
that  then  the  child  will  be  free  from  eczema.  In  all  this  we  think  there  is  a 
great  deal  of  exaggeration,  but  it  is  easy  to  understand  that  a  swollen  and 
tender  gum  may  give  rise  to  a  good  deal  of  crying,  and  some  feverishness, 
and  so  any  eczema,  especially  affecting  the  face,  may  be  aggravated.     It  is 


782  Diseases  of  the  Skin 

perhaps  necessary  to  emphasize  the  important  part  which  scratching  plays  in 
producing  eczemas  in  infants  and  in  preventing  healing. 

Vaccination  is  frequently  blamed  by  the  parents  of  eczematous  children  : 
it  is  certain  that  a  local  eczema  may  arise  at  the  seat  of  the  vesicles,  and  an 
impetigo  be  started  elsewhere  in  consequence  of  scratching  and  inoculation 
of  infective  pus  into  healthy  skin  ;  but  we  do  not  think  that  vaccination  gives 
rise  to  a  g'eneral  eczema. 

What  part  do  micro-organisms  play  in  producing  eczema  ?  It  is  quite 
certain  that  many  cocci  may  be  found  in  every  eczema,  but  it  hardly  can  be 
said  that  they  are  the  cause  of  eczema  in  the  same  sense  that  the  tubercle 
bacilli  are  the  cause  of  lupus  or  phthisis.  Given  a  papular  itching  eczema, 
then  scratching  removes  the  cuticle  and  inoculates  the  broken  skin  with 
cocci,  which  find  a  congenial  soil  in  which  to  flourish.  Much  of  the  chronic 
inflammation  which  follows  is  doubtless  the  result  of  the  growth  of  the  cocci 
thus  inoculated.  Eczema  may  be  self-inoculated,  like  true  impetigo,  by 
scratching.     A  tendency  to  eczema  is  hereditary. 

Symptoms  and  Course. — The  commonest  places  for  eczema  in  infants  and 
young  children  (local  irritants  excluded)  are  the  forehead,  cheeks,  scalp,  and 
backs  of  the  ears.  The  limbs,  especially  the  flexures  of  the  joints  and  backs 
of  the  hands,  are  often  attacked.  The  usual  form  is  eczema  vesiculosum  ; 
in  weakly  and  scrofulous  children  the  pustular  variety,  E.  pustulosum  or 
impetiginodes,  is  the  most  common.  The  former  mostly  begins  with  patches 
of  redness,  the  inflamed  patch  quickly  becoming  the  seat  of  numerous 
papules  ;  in  less  severe  cases  the  papules  may  make  their  appearance  in  crops 
on  apparently  normal  skin.  In  the  worst  cases  the  itching  is  intense,  and 
the  skin  of  the  forehead  or  cheeks  is  hot,  red,  and  oedematous.  The  papules 
quickly  become  vesicular  and  burst,  or  perhaps  more  often  the  inflamed  skin 
begins  to  ooze  without  distinct  vesicles  being  formed.  A  free  discharge 
from  the  skin  usually  gives  relief.  The  skin  continues  to  weep,  perhaps 
for  some  days,  and  probably  also  the  eczematous  patch  is  extending,  cover- 
ing the  whole  forehead  and  affecting  the  cheeks,  so  that  at  this  period  all 
stages  of  the  affection  may  be  seen.  In  one  place  there  may  be  redness 
only,  in  other  places  excoriated  and  weeping  skin  ;  at  another  place  the  dis- 
charge has  dried,  forming  crusts  with  raw,  tender  skin  beneath  ;  where  the 
eczema  is  nearly  well  the  skin  is  thickened  and  the  cutis  desquamating. 
The  skin  of  the  thighs,  flexures  of  the  groin  and  knees,  the  arms  and  back, 
are  very  likely  to  become  affected,  and  as  the  eczema  heals  in  one  place  it 
is  very  likely  to  break  out  in  another.  Sooner  or  later  the  eczema  passes 
into  the  subacute  or  chronic  stage  ;  the  skin  is  more  or  less  red  and  indu- 
rated, there  is  less  oozing  from  the  surface,  while  there  is  a  tendency  to  form 
crusts  and  for  free  desquamation  to  take  place  from  the  skin.  This 
desquamation  or  scurfiness  is  particularly  noticed  on  the  scalp. 

In  some  cases  the  eczema  is  more  of  the  erythematous  type.  The  child 
goes  to  bed  at  night,  and  when  warm  in  bed  the  face  and  forehead  flush  up, 
the  skin  becoming  red,  shiny,  and  hot  ;  the  itching  and  tingling  is  intense, 
so  that  the  child  scratches  and  almost  tears  itself  in  its  restlessness  and  dis- 
comfort, while  sleep  is  out  of  the  question.  In  the  course  of  an  hour  or  two 
the  congested  vessels  are  reheved  by  a  serous  discharge  through  the  perhaps 
already  damaged  skin,    and  the   inflammatory  stage  is  succeeded  by  the 


Eczema  783 

oozing  and  crusting  stage.  The  raw  and  tender  skin  left  after  the  discharge 
more  or  less  recovers  and  dries  up,  and  then  there  is  another  inflammatory 
attack  and  the  process  is  repeated. 

In  weakly  and  scrofulous  children  the  eczema  is  of  a  less  acute  type  ; 
there  is  less  redness,  burning,  and  itching,  and  a  greater  tendency  to  pus  for- 
mation than  when  eczema  occurs  in  strong  and  healthy  children.  The  scalp 
and  face  are  mostly  affected  :  in  these  places  much  crusting  takes  place,  the 
crusts  being  formed  of  dried  pus,  and  on  raising  these  more  or  less  puriform 
fluid  escapes.  In  the  early  stages  pustules  are  usually  present.  In  the 
worst  cases  the  whole  scalp  is  a  mass  of  thick  crusts,  abscesses  form  in  the 
scalp,  glandular  abscesses  are  present  in  the  cervical  glands,  and  perhaps 
'cold  abscesses'  in  various  places  throughout  the  body.  In  dispensary 
practice  an  eczema  pustulosum  of  the  back  part  of  the  scalp  is  almost 
certainly  the  result  of  pediculi. 

All  forms  of  eczema  in  infants  and  young  children  are  apt  to  relapse, 
fresh  attacks  coming  on  before  the  skin  has  entirely  recovered  from  the 
effects  of  the  last  attack,  and  the  old  place  is  soon  as  bad  as  ever.  The 
tendency  is  for  the  attacks  to  involve  the  same  places  time  after  time  where 
the  skin  has  been  injured  or  has  '  contracted  a  bad  habit.'  Often,  however, 
while  healing  in  one  place  it  breaks  out  in  another.  The  younger  the  infant, 
the  more  troublesome  is  the  eczema  ;  the  older  it  grows,  the  less  likely  it  is 
to  relapse. 

The  eczemas,  or  perhaps  more  properly  erythemas,  caused  by  the  con- 
tact of  foul  napkins,  or  by  two  surfaces  of  skin  coming  in  contact  (intei'trigo), 
are  exceedingly  common  in  dispensary  practice  ;  with  ordinary  care  they 
never  occur  in  healthy  children,  but  in  infants  suffering  from  intestinal 
catarrh  or  diarrhoea,  where  the  napkins  are  constantly  soaked  with  the 
excretions,  a  certain  amount  of  soreness  may  be  difficult  to  avoid.  The  skin 
is  usually  at  first  red,  the  erythematous  eruptions  spreading  from  the  anus  and 
genitals  ;  theji  the  horny  layers  of  the  skin  become  detached,  leaving  superficial 
excoriations,  from  which  serum  and  perhaps  blood  may  ooze. 

Eczema  in  older  children  does  not  differ  from  eczema  in  adults.  Any 
part  of  the  body  may  be  affected — -the  face,  trunk,  or  limbs,  and  especially 
the  flexures  of  the  joints.  A  subacute  or  chronic  conjunctivitis  is  commonly 
associated  with  eczema  of  the  face.  The  skin  readily  becomes  red  and  in- 
filtrated, with  a  dry,  rough  surface,  which  readily  cracks,  making  painful  sores. 
The  itching  is  usually  severe,  and  the  affected  part  is  constantly  fretted  and 
irritated  by  the  scratching-  which  goes  on. 

Children  who  suffer  from  eczema  are  usually  constipated. 
Complications. — Children  who  suffer  from  eczema  may  also  be  the  subjects 
of  bronchial  asthma.  In  some  cases  the  two  diseases  are  co-existent,  in 
other  cases  they  alternate  ;  there  is  no  constant  rule  as  far  as  we  have 
been  able  to  determine.  Eczematous  children  frequently  also  suffer  from 
gastro-intestinal  catarrh.  This  is  only  another  way  of  saying  that  there  are 
children  who  are  specially  prone  to  catarrh  of  the  bronchial  tubes,  catarrh 
of  the  stomach  and  bowels,  and  also  to  a  catarrhal  inflammation  of  the 
external  surface  of  the  body.  We  have  already  remarked  that  eczema  and 
impetigo  may  co-exist  in  the  same  subject,  and  so  also  may  seborrhoea. 
It  is  well  known  that  at  times  infants  who  are  suffering  from  eczema. 


784  Diseases  of  the  Skin 

especially  when  extensive,  suddenly  develop  a  high  temperature,  convulsions, 
and  coma,  and  die  in  a  few  hours.  We  have  seen  this  occur  both  in  infants 
in  hospital  and  in  private  practice,  and  do  not  doubt  that  there  has  been 
some  connection  between  the  eczema  and  the  convulsion-fever.  These  cases 
are  well  known  to  the  old  practitioner,  who  regarded  the  fever,  &c.,as  the  result 
of  curing  the  eczema.  This  view  is  certainly  open  to  doubt,  and  need  not 
deter  us  from  using  our  best  endeavours  to  cure  the  disease.  It  is  well, 
however,  to  bear  in  mind  that  a  sudden  and  fatal  illness  may  occur  at  any 
stage  of  the  disease. 

Treatment. — The  most  scrupulous  care  must  be  taken  to  keep  the  healthy 
infant's  skin  clean,  especially  those  parts  which  come  in  contact  with  the 
soiled  napkins.  A  daily  bath  should  be  given  from  the  first  week,  but  a 
prolonged  immersion  must  be  avoided  as  likely  to  macerate  and  soften  the 
cuticle  too  much.  A  good  curd  soap  free  from  excess  of  alkali  should  be 
used,^  and  soft  water  in  preference  to  hard.  Some  starch  powder,  such  as 
finely  ground  rice  or  maize  powder,  with  20  per  cent,  of  boric  acid,  should 
be  applied  after  careful  drying. 

If  the  parts  about  the  genitals  become  red  or  excoriated,  attention  must 
at  once  be  directed  to  the  state  of  the  infant's  digestive  organs  to  see  if 
gastric  and  intestinal  digestion  is  in  a  normal  state,  or  if  there  is  diarrhoea  ; 
and  it  will  probably  be  found  that  something  is  wrong  here.  The  affected 
parts  must  be  kept  clean,  as  little  friction  as  possible  being  used,  and  thin 
gruel,  or  rice  boiled  in  milk,  being  used  instead  of  soap  ;  or  the  parts  may 
be  cleansed  with  a  piece  of  absorbent  cotton-wool  dipped  in  carron  oil. 
(Lime  water  and  linseed  oil  in  equal  parts.)  After  careful  drying,  boric 
acid  powder,  or  oxide  of  zinc  and  starch  (1-5),  kaolin,  or  finely  prepared 
fuller's  earth,  may  be  used  to  dust  on.  Where  there  is  constant  diarrhoea 
the  ordinary  napkin  may  be  dispensed  with,  and  pads  made  of  absorbent 
cotton  or  wood-wool  used  instead,  as  they  more  readily  absorb  the  fseces 
and  urine.  Unna's  '  powder-bags '  are  sometimes  useful ;  these  are  bags 
made  of  soft  fine  muslin,  and  filled  with  some  dusting  powder,  as  zinc 
and  starch,  or  Taylor's  cimolite,  and  quilted,  to  prevent  the  powder  from 
gravitating  to  one  end.  These  bags  may  be  made  ready  and  used  as  re- 
quired ;  their  value  consists  in  keeping  the  parts  dusted  by  the  powder, 
which  escapes  through  the  pores  of  the  linen  or  muslin. 

The  dietetic  treatment  of  general  eczema  is  often  difficult,  as  it  may  be 
by  no  means  clear  that  anything  is  wrong  with  the  digestive  organs.  If  the 
infant  is  being  nursed  at  the  breast,  great  care  should  be  exercised  by  the 
mother  as  regards  her  diet  :  beer,  tea,  coffee,  salt  meats  or  greasy  dishes,  are 
best  avoided,  or  taken  only  in  moderate  quantities,  while  milk,  fish,  fresh 
meat,  and  vegetables  maybe  taken  freely.  The  infant,  if  vigorous  and  full- 
blooded,  is  perhaps  taking  too  much  breast-milk,  and  the  amount  should 
be  lessened.  Possibly  the  breast-milk  may  be  poor  in  quality — containing 
an  excess  of  sugar,  while  deficient  in  proteids  and  fat— and  the  infant  is  flabby, 
poorly  nourished,  and  suffers  in  consequence  from  impetigo  or  intertrigo  ;  in 
which  case  some  form  of  artificial  food  must  be  given  in  addition  to  the  breast- 
milk.    In  artificially  reared  children  the  question  of  diet  is  of  great  importance  : 

1   Unna's  '  over-f;itty '  soap  or  '  Vinolia  '  soap  makes  a  good  soap  for  infants. 


Treatment  of  Eczema  785 

eczematous  infants  b(?ing  brought  up  on  cow's  milk  are  frequently  constipated 
and  pass  large  quantities  of  undigested  curd  in  their  stools.  In  such  cases 
some  form  of  modified  or  humanised  milk  or  whey  should  be  given.  In 
older  children,  especially  if  there  is  an  excess  of  fat,  starchy  and  saccharine 
foods  should  be  avoided,  and  the  diet  confined  as  much  as  possible  to  milk, 
cream,  eggs,  broth,  underdone  minced  meat,  and  green  vegetables. 

The  medicinal  treatment  must  be  directed  to  overcoming  the  constipation 
so  often  present,  and  exciting  the  action  of  the  liver  ;  small  doses  of  mercury, 
euonymin,  or  rhubarb  and  soda  may  be  prescribed.  (F.  95  or  96.)  Small 
doses  of  Rubinat  or  Hunyadi  water  are  often  successful. 

Of  other  internal  remedies  in  the  acute  stages,  alkalis,  such  as  the  citrate 
or  bicarbonate  of  potass,  with  nux  vomica,  are  frequently  useful.  Effervescing 
citrate  of  potass  and  lithia  is  useful,  acting  both  on  the  bowels  and  kidneys. 
Carlsbad  salts,  taken  in  warm  water  before  breakfast  several  times  a  week, 
may  be  prescribed  in  older  children.  Arsenic  is  rarely,  if  ever,  of  use  in 
the  early  stages  of  infantile  eczema  ;  indeed,  we  have  seen  cases  which 
wei'e  made  distinctly  worse  by  it.  In  many  cases  in  infants  a  dose  of  two  or 
three  grains  of  choral  hydrate  (infant  six  months)  will  secure  a  good  night 
and  prevent  scratching.  In  older  children  in  the  chronic  stages,  where  there 
is  a  disposition  to  excessive  desquamation,  arsenic  is  usually  beneficial.  In 
the  chronic  impetiginous  eczemas  of  scrofulous  children  cod-liver  oil  and  the 
iodides  may  be  prescribed  with  great  advantage.  Cod-liver  oil  and  arsenic 
may  be  given,  or  arsenic  can  be  added  to  some  ready-made  cod-liver  oil 
emulsion.     (F.  97.) 

In  the  management  of  local  remedies  much  depends  upon  how  the 
application  is  used,  and  much  time  and  trouble  may  be  well  bestowed  in 
showing  the  friends  of  patients  how  to  apply  the  dressings,  and,  what  is  by 
no  means  easy,  to  keep  them  in  position.  Merely  smearing  on  an  ointment 
or  dabbing  on  a  lotion  may  be  an  entirely  valueless  proceeding  ;  moreover, 
the  newly  formed  cutis  is  very  easily  injured.  The  ointment  or  lotion  re- 
quires to  be  kept  in  constant  contact  with  the  part  if  it  is  to  be  of  any  use. 
In  infants  and  young  children  some  method  will  have  to  be  adopted  to 
prevent  scratching  ;  mittens  must  be  placed  on  the  hands,  and  in  some  cases 
it  may  be  necessary  to  secure  the  arms  by  means  of  bandages. 

For  application  locally  the  range  of  remedies  is  very  wide,  and  various 
combinations  have  been  called  into  requisition  in  the  way  of  lotions, 
liniments,  and  ointments.  As  a  rule,  in  all  acute  eczemas,  where  there  is 
much  excoriation  of  the  skin,  or  thin  newly  formed  skin  is  present,  much 
washing  or  rough  handling  should  be  avoided.  On  the  other  hand,  in 
chronic  cases,  where  the  skin  is  thick,  scaly,  or  infiltrated,  baths  are  of  great 
service  in  removing  the  scales  and  softening  the  skin.  In  all  eczemas,  how- 
ever, a  certain  amount  of  cleansing  is  necessary  to  remove  the  remains  of 
the  old  ointments  and  crusts  :  this  can  usually  be  done  by  gently  applying 
some  almond  oil — or  carron  oil  answers  very  well — ordinary  soap  being  best 
avoided  in  acute  cases. 

In  all  acute  or  subacute  eczemas  soothing  remedies  are  required,  and 
must  be  perse\ered  in  as  long  as  there  is  an  irritable  condition  of  the  skin 
and  free  discharge.  The  most  troublesome  eczemas  in  infancy  are  those  of 
the  face.     In  these,  when  the  skin  flushes  up  and  is  hot  and  angry  during 

^  E 


786  Diseases  of  the  Skin 

the  evening  exacerbation,  and  the  infant  sleepless  and  restless  from  the 
burning  and  itching  of  the  skin,  hot  poppy-head  or  boric  fomentations  often 
give  relief.  Perhaps  more  often  cooling  applications  are  the  most  grateful, 
and  for  this  purpose  carron  oil,  with  or  without  ichthyol,  may  be  applied  on 
lint  and  kept  in  place  with  a  bandage.     (F.  98,  99,  100.) 

When  the  eczema  has  passed  into  the  scaly  stage,  and  there  is  no  large 
amount  of  discharge  from  the  skin,  more  stimulating  ointments  may  be  used 
and  the  face  kept  continuously  bound  up  to  exclude  the  air.  There  should 
be  a  daily  cleansing  with  carron  oil  to  remove  the  excess  of  ointment  and 
the  accumulated  scabs,  and  now  Lassar's  or  Ihle's  pastes  are  useful  to  form  a 
protective  covering  to  the  newly  formed  skin,  but  they  are  difficult  to  remove 
if  allowed  to  cake  on  to  any  extent.     (F.  103,  104.) 

In  acute  general  eczema,  where  large  surfaces  of  the  body  are  affected, 
liniments  applied  on  rag  or  lint  should  be  used,  and  the  parts  firmly 
bandaged  with  gauze  bandages  so  that  the  application  maybe  kept  in  constant 
contact  with  the  skin.  When  there  is  much  discharge  and  the  skin  inflamed 
and  tender,  it  is  sometimes  best  simply  to  powder  on  some  finely  ground 
boric  acid  and  surround  the  limb  with  absorbent  wool,  firmly  bandaged 
on  ;  or  strips  of  lint  may  be  saturated  with  carron  oil  or  calamine  liniment. 
(F.  98,  99.)  In  a  later  stage,  when  the  skin  is  thickened  and  scaly,  with 
but  little  or  no  discharge,  more  stimulating  applications  containing  sulphur, 
ichthyol,  zinc,  or  lead  are  usually  prescribed.  (F.  102,  108.)  The  ointment 
should  be  of  tolerably  firm  consistence,  so  as  not  to  melt  too  readily  and  run 
into  the  lint.  Ung.  paraffini  B.P.  is  one  of  the  best.  Mercurial  ointments 
should  not  be  applied  to  an  extensive  surface  of  skin  or  too  continuously 
for  fear  of  mercurial  poisoning. 

In  impetigo,  where  the  discharge  is  more  or  less  purulent  and  much 
scabbing  takes  place,  the  scabs  should  be  removed  by  poultices  or  carbolic 
oil,  and  some  diluted  mercurial  ointment  (F.  106,  109) — or  an  ointment 
consisting  of  five  or  ten  grs.  of  iodoform  to  the  ounce — may  be  applied. 

Eczema  affecting  the  scalp  must  be  treated  in  a  similar  manner  to  that  of 
the  face,  except  that,  as  a  rule,  more  stimulating  applications  may  be  applied. 
In  the  weeping  and  irritable  stage  carron  oil  or  the  calamine  liniment  or 
zinc  and  cold  cream  may  be  applied  on  lint  or  rags,  and  a  nightcap  worn  by 
the  child  to  protect  the  parts  and  prevent  the  infant  from  scratching.  The 
hair  must  be  kept  short  and  the  scalp  cleansed  every  morning  with  some 
mild  soap  and  warm  water  ;  or  thin  gruel  may  be  used.  In  the  more  chronic 
stages,  especially  in  neglected  cases,  the  crusts  must  be  removed  by  oiling 
and  poulticing,  and  some  diluted  white  precipitate  ointment  or  other  mild 
mercurial  ointment  applied.  Lassar's  or  Ihle's  paste  (F.  103,  104)  may  be 
used,  being  put  on  thickly,  and  the  head  covered  with  a  cap  made  of  old 
linen,  or  what  is  known  as  '  butter-cloth  ; '  the  crusts  and  excess  of  ointment 
must  be  removed  daily  or  every  few  days.  Eczema  of  the  scalp,  the  result 
of  pediculi,  should  be  treated  by  poulticing,  cutting  the  hair,  and  the 
continuous  application  of  white  precipitate  ointment. 

In  the  chronic  general  eczemas  of  older  children,  especially  where  the 
skin  is  rough  and  coarse,  and  there  is  much  infiltration,  and  the  flexures  of 
the  joints  are  affected,  baths  and  stimulating  liniments,  followed  by  some 
soothing   protective    omtment,   usually  answer  best.       Soft  soap,  the  pure 


Treatment  of  Ecscina  787 

green  variety,  may  be  rubbed  over  the  parts  on  a  wetted  flannel  for  a  minute 
or  two  so  as  to  soften  the  skin  ;  it  is  then  washed  off  in  a  warm  bath,  the 
child  dried,  and  some  strips  of  lint  coated  with  zinc  and  lead  ointment 
applied.  This  plan  answers  well  in  hospital,  but  the  application  of  the  soft 
soap  causes  smarting,  and  in  private  practice  the  child's  friends  are  apt  to 
think  it  makes  the  eczema  worse  and  fail  to  persevere.  Instead  of  the  soft 
soap,  the  old  ointment  having  been  cleaned  off,  the  parts  may  be  sponged 
with  lead  and  carbolic  lotion  (F.  107)  every  evening  for  a  few  minutes, 
and  this  treatment  should  be  followed  by  simple  zinc  or  lead  ointment. 

In  local  eczemas,  especially  those  about  the  nose,  back  of  the  ears,  and 
flexures  of  the  joints,  Unna's  salve  plaisters  or  salve  muslins  are  very  con- 
venient and  efficacious.  Pieces  of  these  can  be  cut  with  the  scissors  to  any 
shape,  and  when  placed  over  the  patch  of  eczema  can  be  readily  held  in 
position  by  a  light  bandage.  The  zinc  and  red  oxide  of  mercury  salve 
muslin  and  tar  and  lead  are  the  most  useful. 

Xmpetigro  Contag-iosa,  Staphylococcia. — This  eruption  is  charac- 
terised by  the  formation  of  crops  of  vesicles  of  various  sizes,  which  become 
converted  into  pustules.  The  pustules  dry  up  or  become  ruptured,  leaving 
a  greenish-yellow  thick  scab.  The  eruption  is  most  common  about  the  face, 
especially  round  the  mouth  ;  it  may  also  occur  about  the  neck,  hands,  and 
feet.  In  some  cases  there  is  marked  febrile  disturbance  before  the  vesicles 
appear.  When  the  patient  is  seen  for  the  first  time,  after  having  been 
affected  for  several  days  or  a  week,  but  few  vesicles  may  be  present,  and 
only  scabs  and  crusts  visible  on  the  face  and  back  of  the  neck.  Deep 
ulcers  may  form  at  the  seat  of  the  pustules.  The  disease,  as  its  name 
implies,  is  contagious,  being  transferred  by  means  of  the  nails  from  one  part 
of  the  body  to  another,  and  from  one  child  to  another  in  a  similar  way.  The 
attacks  may  be  acute  in  character,  and  the  constitutional  disturbance  severe. 
It  occurs  in  cachectic  children  and  is  rarely  seen  except  in  hospital  practice. 
It  may  follpw  midge  bites.  There  is  a  close  resemblance  between  impetigo 
contagiosa  and  some  forms  of  eczema.  Indeed  we  should  say  clinically 
there  is  no  sharp  line  of  demarcation  between  them.  The  treatment  con- 
sists in  removing  the  scabs  by  oiling  or  poulticing,  and  applying  dilute 
white  precipitate  or  sulphur  ointment  on  lint.  Cod-liver  oil  should  be 
given  internally. 

Seborrhoea. —  Seborrhoea  is  a  '  functional  disorder  of  the  sebaceous  glands, 
producing  increase  of  the  secretion,  which  forms  an  oily,  waxy,  or  scaly 
accumulation  on  the  surface.'     (Crocker.) 

The  most  familiar  example  of  this  disorder  is  seen  in  dispensary  practice 
in  infants  who  are  badly  looked  after  and  rarely  washed  ;  in  such  there  is  often 
an  accumulation  of  a  dirty  yellow  material  over  the  anterior  fontanelle,  which 
can  be  scraped  off  with  a  blunt  instrument.  A  certain  amount  of  eczema 
may  be  present.  What  has  been  termed  '  dry  seborrhoea '  is  not  uncommon 
in  the  scalp  of  older  children  ;  it  may  occur  also  on  the  face  as  well  as  on 
the  trunk  and  limbs  ;  the  scalp  is  dry  and  covered  with  small  scales  or  scurf, 
which  fly  out  when  the  head  is  combed  or  brushed.  Care  must  be  taken 
not  to  mistake  diffused  ringworm  of  the  scalp  for  simple  seborrhoea. 

Treatment. — The  excessive  sebaceous  secretion  on  the  scalp  of  infants 
can  usually  be  removed  by  gentle  friction  with  a  piece  of  flannel  dipped  in 


788  Diseases  of  the  Skin 

\\arm  oli\e  or  almond  oil,  following"  this  up  with  washing"  with  soap  and 
\\ater  ;  this  process  may  want  repeating  once  or  twice,  and  care  must  be 
taken  to  keep  the  child's  head  well  washed.  If  there  is  a  tendency  to  exces- 
sive secretion,  a  little  ung.  hydrarg.  ox.  flav.  (5  per  cent,  in  vaseline)  or  ung. 
boracis  (5ss  ad  5]  benzoated  lard)  should  be  applied.  For  dry  scaly  patches 
on  the  face  an  ointment  consisting"  of  precipitated  sulphur  in  cold  cream  (5ss 
ad  5J)  may  be  used. 

Erythematous  Eruptions.^The  term  '  erythema '  is  applied  to  those 
eruptions  which  consist  in  a  redness  or  congestion  of  a  more  or  less  extended 
portion  of  skin,  as  well  as  to  other  eruptions,  where  there  is  not  only  a  con- 
gestion, but  an  actual  exudation  from  the  cutaneous  vessels,  as  in  erythema 
nodosum. 

A  simple  erythema  or  congested  portion  of  skin  occurs  under  various 
conditions  ;  it  may  be  the  result  of  some  external  irritation,  such  as  the  con- 
tact of  foul  napkins  ;  the  application  of  various  irritants,  such  as  mustard, 
chrysarobin,  arsenic  ;  or  the  bites  of  insects.  An  erythema  sometimes  pre- 
cedes the  eruptions  of  the  specific  fevers  :  this  occurs  at  times  in  small-pox, 
chicken-pox,  vaccinia  ;  and  it  accompanies  other  febrile  disorders,  which  are 
not  usually  accompanied  by  a  rash,  as  diphtheria,  cholera,  and  septic£emia. 
An  erythematous  redness  is  often  present  when  there  is  a  high  temperature, 
as  in  pneumonia  and  other  febrile  disorders.  An  idiopatbic  erythema 
or  roseola  is  not  uncommon  in  infants  and  young  children,  mostly  as 
the  result  of  some  intestinal  irritation,  possibly  also  due  to  the  iritation  of 
the  gum  caused  by  dentition.  It  is  more  or  less  patchy  in  its  distribution, 
occurring  on  the  forehead,  face,  trunk,  or  limbs  ;  there  may  be  no  marked 
constitutional  disturbance,  and  the  patches  of  redness  may  be  the  first 
symptom.  In  other  cases  there  may  be  several  degrees  of  fever,  restless- 
ness, and  perhaps  vomiting.  The  eruption  is  mostly  fugitive,  disappear- 
ing in  a  few  hours  to  twenty-four  hours.  Other  patches  may  appear  as  the 
first  ones  fade. 

Erythema  Scarlatiniforme. — Is  a  typical  'scarlet  fever  rash'  ever 
present  in  any  non-scarlatinal  case  ?  It  is  difficult  to  answer  this  question 
dogmatically,  but  it  may  certainly  be  said  that  in  any  case  when  there  is  a 
diffuse,  well-marked,  punctiform  rash,  remaining"  visible  for  at  least  twenty- 
four  hours,  the  disease  is  almost  certainly  scarlet  fever  or  rubella.  It  is 
certain,  however,  that  some  erythematous  or  roseolous  rashes  do  closely 
resemble  scarlet  fever,  and,  as  they  are  attended  not  infrequently  with  some 
constitutional  disturbance  and  fever,  the  difficulty  in  diagnosis  may  be  very 
great. 

Some  children  are  especially  liable  to  roseolous  rashes  resembhng  scarlet 
fever,  as  the  result  of  indigestion  or  some  other  source  of  irritation  ;  a  roseo- 
lous rash  is  also  apt  to  occur  in  septic  conditions,  such  as  in  an  empyeina,  or 
wherever  pus  is  shut  up  in  a  cavity. 

The  constitutional  disturbance  in  these  cases  is  generally  slight  ;  the 
temperature  may  reach  101°  or  102°  F.,  the  tongue  may  be  slightly  coated, 
but  the  child  usually  feels  quite  well  and  his  appetite  is  normal.  The  rash 
may  very  closely  resemble  mild  scarlet  fever  ;  it  is,  however,  as  far  as  our 
experience  goes,  never  so  intense  as  it  is  in  a  typical  or  well-marked  case  of 
scarlet  fever  ;  moreover,  in  some  part  of  the  body  it  is  almost  sure  to  be 


Erythema  Scarlatiniforme  789 

patchy  and  unlike  scarlet  fever.  The  distinction  between  a  roscolous  and  a 
scarlet-fever  rash  may  be  difficult  or  impossible  if  one  part  of  the  body  only 
happens  to  be  seen,  but  the  difficulty  usually  disappears  if  a  careful  examina- 
tion of  the  whole  body  be  made,  as  in  some  places,  especially  the  face  and 
trunk,  the  roseola  is  patchy,  the  patches  having  a  sharp  outline.  Crocker 
speaks  of  a  roseolous  rash  lasting  two  to  six  days,  and  followed  by  a  more  or 
less  copious  desquamation.  We  have  never  seen  such  a  case,  and  should  be 
extremely  suspicious  of  scarlet  fever  in  such  cases.  In  our  experience  an 
erythematous  or  roseolous  rash,  while  it  may  closely  resemble  a  scarlet-fever 
eruption,  is  more  fugitive,  and  rarely  lasts  more  than  twenty-four  or  forty- 
eight  hours,  and  is  not  followed  by  desquamation.  In  the  majority  of  cases 
the  presence  or  absence  of  a  tonsillitis  will  decide  the  diagnosis. 

A  roseolous  rash  may  follow  the  taking  of  certain  drugs,  more  especially 
belladonna,  copaiba,  and  salicylic  acid. 

Erythema  Pernio,  Chilblains. — Children  with  slow  circulations, 
especially  the  so-called  strumous,  are  very  apt  to  suffer  from  chilblains.  The 
favourite  spots  are  the  toes,  heel,  and  fingers  ;  they  begin  with  redness  and 
intense  itching,  or  aching,  coming  on  towards  evening,  or  when  the  patient 
is  warm.  The  skin  is  smooth,  livid,  and  shiny,  and  ulceration  may  take 
place  if  it  is  subjected  to  much  friction.  Children  subject  to  chilblains  should 
wear  warm  woollen  stockings  and  well-fitting  boots  with  broad  toes  and 
thick  soles,  and  should  take  much  exercise.  In  the  early  stages  the  affected 
parts  may  be  painted  with  equal  parts  of  tr.  iodi  and  Hn.  aconiti,  or  lin. 
saponis  co.  with  an  equal  quantity  of  lin.  belladonnas.  A  mild  capsicum 
ointment  also  answers  well  (capsici  5ss,  almond  oil  5ij)  lanoline  5vj),  rubbed 
in  with  a  piece  of  flannel.  Zinc  ointment  with  ung.  hydrarg.  ox.  rubri,  or 
ung.  picis  liq.,  in  varying  proportion  according  to  the  stimulating  effect  desired, 
may  be  applied. 

Erythema  IMCultiforme  is  mostly  seen  during  early  life  in  association 
with  rheumatism,  or  in  rheumatic  subjects  ;  whatever  importance  it  possesses 
is  derived  from  this  association.  The  outbreak  of  this  form  of  erythema  is 
always  suggestive  of  the  rheumatic  state,  and  an  examination  of  the  heart 
or  endocarditis  should  always  be  made.  The  most  common  form  consists 
in  red  papules  surrounded  by  more  or  less  congested  skin.  In  association 
with  the  papules  there  may  be  flat  raised  patches  surrounded  by  a  zone  of 
redness  (erythema  marginatum).  Sometimes  the  eruption  becomes  purpuric, 
and  bullce  or  vesicles  may  form. 

Erythema  TTodosum  has  apparently  a  close  relationship  to  the  erythema 
just  described,  though  the  constitutional  disturbance  is  often  much  greater. 
Prior  to  the  appearance  of  the  nodes  there  may  be  rheumatic  pains  and  fever, 
the  temperature  perhaps  reaching  103°  or  104°,  and  the  child  is  apparently 
quite  ill  (see  fig.  48).  The  eruption  appears  most  copiously  over  the  shins, 
but  the  arms,  especially  on  the  extensor  surfaces,  or  any  part  of  the  body,  may 
be  attacked  ;  it  appears  as  node-like,  tender,  red  swellings  of  various  sizes, 
accompanied  by  a  burning  or  itching  sensation.  The  patches  come  out  two 
or  three  at  a  time  in  various  parts  of  the  body.  At  first  rose-red  in 
colour,  they  then  assume  a  darker-red  colour,  and  as  they  disappear  become 
of  a  yellow  colour  like  a  fading  bruise. 

Not  much  treatment  is  required  for  erythema  multiforme  or  nodosum 


790  Diseases  of  the  Skin 

A  light  milk  diet,  a  mild  aperient  with  some  saline,  with  salicylate  of  soda  if 
rheumatism  is  suspected.  Locally,  lead  lotion  with  some  tr.  opii  or  liq.  car- 
bonis  detergens  may  be  used. 

Urticaria  is  characterised  by  the  sudden  appearance  of  elevated  blotches 
or  wheals,  at  first  red  in  colour,  afterwards  becoiTiing  white  and  sur- 
rounded by  a  zone  of  redness.  They  are  attended  by  much  burning  and 
itching.  The  blotches  usually  disappear  in  the  course  of  a  few  hours,  but 
most  frequently  there  are  successive  crops.  In  some  cases  a  certain 
amount  of  oedema  is  produced  by  urticaria  ;  we  have  seen  children  with 
oedema  of  the  eyes  and  backs  of  the  hands  following  nettle-rash.  There  is 
usually  some  gastro-intestinal  disturbance.  Urticaria  is  sometimes,  espe- 
cially in  infants,  a  distressing  and  troublesome  complaint,  the  intense  itching 
making  the  child  restless,  and  entirely  preventing  sleep.  Urticaria  is  the 
result,  in  the  large  majority  of  instances,  of  some  irritation  in  the  alimentary 
canal,  less  often  of  teething ;  sometimes  it  is  due  to  the  bites  of  insects 
or  scabies.  Worms  are  not  an  uncommon  cause  in  young  children  ;  fruits 
of  various  kinds,  especially  strawberries,  fish,  sausages,  stale  meat,  sour 
milk,  or  any  kind  of  fruit  which  disagrees,  may  act  as  a  cause. 

The  most  troublesome  form  of  urticaria  is  that  variety  known  as  urticaria 
papulosa  or  lichen  urticatus.  This  is  a  very  intractable  affection  and 
may  last  for  many  months  or  even  years.  When  seen  in  dispensary  practice 
it  is  very  apt  to  be  mistaken  for  scabies,  as  the  rash  consists  of  numerous 
papules  ;  many  are  often  scabbed  over  as  the  result  of  scratchings  about  the 
body,  limbs,  hands,  and  feet.  In  the  Avcjrst  cases  the  whole  body  is  covered 
with  itching  papules,  which  in  some  places  perhaps  become  pustular,  making 
the  resemblance  to  scabies  a  very  close  one,  but  no  '  burrows '  can  be  dis- 
covered. The  eruption  begins  as  small  wheals,  which  become  papules, 
fresh  ones  coming  out  every  night  in  crops  when  the  child  goes  to  bed. 
Rest  is  broken,  and  health  may  be  seriously  interfered  with.  It  is  most 
common  during  the  period  of  the  first  dentition,  and  the  tendency  to  it 
mostly  disappears  at  three  or  four  years  of  age.  In  the  milder  cases  there 
is  a  succession  of  papules,  some  of  which  are  surmounted  by  a  small  vesicle, 
which  is  quickly  broken  by  scratching.  After  two  or  three  days  the  rash 
ceases  to  make  its  appearance,  to  return  perhaps  in  a  few  weeks.  Gene- 
i-ally  speaking,  urticaria  is  more  common  in  summer  than  winter. 

In  some  children  fleas  and  other  insects  will  pi'oduce  vesicles  as  well  as 
papules,  and  give  rise  to  more  or  less  constitutional  disturbance. 

Treatment. — An  aperient  should  be  given,  calomel  or  rhubarb  and  soda 
being  the  best.  Santonin  and  calomel  maybe  given  if  worms  are  suspected. 
A  saline  such  as  citrate  of  potash  or  bromide  of  potassium  may  be  ordered. 
Locally,  sponging  the  wheals  with  lead  and  tar  lotion  (such  as  F.  107)  is 
perhaps  the  best  application,  or  each  wheal  may  be  rubbed  with  menthol  or 
painted  with  collodion.  Sulphur  baths  (sulphuret  of  potassium,  5ij  to  a  bath) 
are  useful  in  the  chronic  varieties. 

lichen  Scrofulosus  '  is  characterised  by  very  small  inflammatory  papules 
of  a  red  colour,  fading  to  that  of  the  normal  skin,  disposed  in  groups  or  circles, 
and  occurring  mainly  in  scrofulous  subjects.'     (Crocker.) 

This  form  of  lichen  is  not  common  in  our  experience,  but  it  is  easily 
overlooked,  inasmuch  as  it  is  unattended  with  any  great  inconvenience  to  the 


Lie  hoi  Scrofulosits  791 

patients  :  they  may  make  no  complaint,  and  it  is  only  discovered  accidentally. 
The  important  points  in  the  diagnosis  consist  in  the  absence  of  irritation 
and  the  presence  of  caseous  lymph  glands  or  other  well-marked  evidence  of 
scrofula.  The  papules  are  small,  and  of  a  bright  red  colour  at  first,  gradually 
changing  to  dull  red,  then  desquamating,  and  finally  leaving  a  brown  stain. 
They  must  be  present  on  the  trunk  or  limbs.  Their  course  is  very  chronic, 
fresh  papules  appearing  as  the  old  ones  fade,  so  that  the  patient  may  not  be 
entirely  free  for  months  or  years. 

Psoriasis. — This  affection  is  common  in  children  over  three  years  of 
ag"e,  but  is  seldom  so  severe  or  so  intractable  as  it  often  is  in  adults.  It  is 
perhaps  even  more  liable  to  recur  in  children  than  in  adults.  The  symptoms 
are  so  similar  during  childhood  to  those  seen  in  after  life  that  no  detailed 
description  is  necessary.  The  treatment  we  usually  adopt  is  to  give  arsenic, 
beginning  with  two-minim  doses  and  gradually  increasing  it  ;  warm  baths, 
with  the  moderate  use  of  green  soft  soap  to  remove  the  scales,  and  the 
application  of  some  tarry  or  mercurial  ointment.  In  hospital  patients  we 
have  used  Auspitz's  solution  of  chrysarobin  with  great  success.  The  solution 
is  applied  to  the  spots  twice  a  week,  a  patient  wearing  old  linen  to  avoid 
damage.     (F.  109,  no.) 

Pityriasis  Rubra. — We  have  occasionally  seen  this  disease  in  children, 
but  it  is  comparatively  rare.  The  best  marked  case  was  in  a  girl  of  eight 
years  who  was  in  hospital  twice  with  a  precisely  similar  attack.  The  rash 
appeared  to  commence  on  the  chest,  and  spread  over  the  arms,  trunk,  and 
extremities.  It  consisted  of  a  red  rash  covered  with  fine  thin  scales.  Both 
attacks  pi-oved  very  chronic.  A  lotion  of  bichloride  of  mercury  (1-5000)  was 
used,  but  had  to  be  stopped  on  account  of  salivation. 

Miliaria.  Sudamina. — In  various  fevers,  such  as  scarlet  fever,  enterica, 
and  in  other  febrile  disorders,  as  rheumatism,  a  number  of  minute  vesicles 
with  clear  contents  make  their  appearance  on  the  skin.  The  clear  fluid  is 
sweat,  which  has  been  unable  to  escape  from  the  orifice  of  the  sweat  gland  ; 
the  contents  of  the  vesicles  are  absorbed  or  dried  up  in  a  day  or  two,  leaving 
a  tiny  desquamating  spot.  In  other  cases  a  slight  inflammation  occurs  at 
the  blocked'sweat  gland,  and  a  minute  papule  appears  instead  of  the  vesicle, 
though  vesicles  may  also  be  present  ;  this  condition  has  been  called  IVIiliaria 
rubra.  The  so-called  Itichen  strophulus  or  'red  g-um'  is,  according  to 
Crocker,  a  sweat  rash  ;  it  consists  of  minute  crops  of  red  papules  which 
make  their  appearance  in  infants  ;  they  are  attended  often  with  much  itch- 
ing and  consequent  restlessness  of  the  infant.  A  somewhat  similar  rash  has 
been  attributed  to  dentition  as  well  as  to  gastric  irritation.  The  papules 
should  be  dabbed  with  the  lotion  F.  99  or  F.  100,  and  powdered  with  boric 
acid  or  some  drying  dusting  powder. 

Pempbigus  is  rare  in  infants  apart  from  syphilis,  but  attacks  of  the 
acuter  form  of  the  disease  {^Pemphigus  neonatorum)^  occurring  in  epidemics 
in  lying-in  hospitals  or  in  the  practice  of  a  midwife,  have  been  recoi'ded  by 
continental  writers.  In  these  cases  the  disease  appears  to  have  been  dis- 
tinctly contagious  :  not  only  has  it  apparently  passed  from  infant  to  infant, 
Ijut  also  from  infant  to  nurse.  In  a  few  cases  the  eruption  is  preceded  by 
fever,  restlessness,  or  convulsions  ;  the  rash  usually  appears  at  the  end  of 
the  first  week.     The  bullae  vary  in  size  ;  their  contents  are  clear  or  slightly 


79-  Diseases  of  the  Skin 

cloudy,  rarely  pustular  ;  they  gradually  dry  up,  forming  superficial  ulcers  or 
crusts.  All  parts  of  the  body  may  be  attacked,  and,  unlike  syphilitic  pem- 
phigus, there  is  no  preference  for  the  palms  of  the  hands  or  soles  of  the  feet. 

Chronic  pemphigus  is  seen  occasionally  in  older  children  ;  in  some  of 
these  cases  the  children  appear  to  be  in  good  health  and  complain  of  nothing 
except  the  eruption,  for  which  no  cause  can  be  assigned.  In  most  cases 
there  is  marked  anaemia,  and  more  or  less  fever  and  constitutional  dis- 
turbance ;  the  latter  may  be  severe.  The  number  of  bullae  varies  from  two 
or  three  to  perhaps  twenty  ;  they  appear  as  vesicles  on  the  face,  trunk,  and 
limbs,  gradually  enlarging,  and  finally  drying  up  in  the  course  of  a  few  days. 
The  treatment  consists  in  giving  arsenic  in  full  doses,  and  cod-liver  oil. 
Locally,  boric  acid  or  zinc  ointment  may  be  applied.  In  tne  severer  cases 
continuous  baths  are  useful. 

Sermatitis  Gan^rsenosa  Infantum. — In  speaking  of  varicella  we  have 
referred  to  a  peculiar  form  of  multiple  gangrene  of  the  skin,  which  is  apt  to 
follow  varicella  in  anaemic  or  emaciated  children  (pp.  307,  308).  There  is 
reason  to  believe  that  this  condition  is  not  necessarily  preceded  by  varicella, 
but  may  follow  other  pustular  eruptions  (Crocker)  ;  it  has  been  known  also 
to  follow  vaccination.  It  almost  always  occurs  in  infants  or  young  children 
under  three  years  of  age,  and  in  many  of  the  fatal  cases  tuberculosis  has  been 
found.  In  these  cases  the  varicella  vesicle  or  pustule  is  succeeded  by  an 
ulcer,  which  rapidly  extends  in  size  and  depth,  several  frequently  joining 
together,  so  as  to  form  large  sinuous  ulcers  ;  the  floor  becomes  black  from 
the  formation  of  sloughs.  In  the  worst  cases  the  scalp,  face,  body,  and  limbs 
are  covered  with  sloughy-looking  ulcers,  either  separate  or  confluent.  There 
may  be  marked  constitutional  symptoms.  In  one  of  our  cases  there  was 
recovery,  the  ulcers  gradually  healing  up  ;  in  the  majority  of  cases  a  fatal 
result  ensues.  The  treatment  consists  in  giving  the  child  a  generous  diet, 
including  beef  tea  and  wine,  and  dressing  the  ulcers  with  iodoform  or  other 
antiseptic  ointment. 

Dermatitis  ISxfoIiata  Infantum. — It  is  not  uncommon  to  find  infants  a 
few  weeks  old  with  a  diffused  red  rash  which  desquamates  freely,  the  skin 
coming  off  in  scales  or  flakes.  The  skin  is  thickened,  red  and  shiny,  cracks 
or  fissures  appear  round  the  lips,  and  in  places  large  ulcers  may  form, 
especially  over  the  sacrum.  The  disease  usually  begins  during  the  first 
week  or  two  of  life,  the  infant  suffers  from  marasmus,  with  perhaps  vomiting 
or  diarrhoea.  It  is  usually  fatal.  This  disease  is  often  mistaken  for  syphilis, 
especially  as  there  may  be  some  coryza  and  the  eruption  first  make  its 
appearance  about  the  buttocks  or  '  napkin  area.'  It  has,  however,  nothing 
to  do  with  syphilis,  but  is  probably  a  form  of  septicaemia.  It  apparently 
occurs  most  frequently  in  Foundling  Asylums.  In  all  the  cases  we  have 
seen  the  infant  has  been  artificially  fed. 

Srugr  Eruptions. — The  most  important  rash  belonging  to  this  class  is  the 
Bromide  eruption.  In  some  children  a  few  grains  of  a  bromide  salt  are 
suflicient  to  cause  a  rash,  while  in  other  cases  the  salt  may  be  taken  for 
weeks  or  months  together  without  giving  rise  to  any  eruption.  Infants 
perhaps  are  more  liable  than  older  children.  The  eruption  consists  in  most 
cases  of  a  red  papular  rash,  the  papules  being  discrete  and  occurring  chiefly 
on  the  face,  scalp,  trunk,  and  limbs.     On  the  summit  of  the  red  papules  are 


Ringivorvi  of  the  Scalp  793 

one  or  more  yellowish  points,  or  small  pustules.  The  rash  looks  more  like 
acne  than  any  other  rash.  It  is  sometimes  confluent.  Scabbing  and  ulcera- 
tion may  take  place.  We  have  seen  the  scabs  and  ulcers  an  inch  in 
diameter  on  the  limbs. 

A  somewhat  similar  rash  also  occurs  after  taking  Iodides,  but  it  is  less 
common.  Antipyrin  and  Phenacetin  in  some  recorded  cases  have  given 
rise  to  a  '  measly'  eruption  or  an  urticaria.  We  have  several  times  noted  a 
papular  rash  after  giving  antipyrin.  The  long  administration  of  Arsenic  is 
sometimes  followed  by  a  darkening  of  the  skin,  especially  marked  on  the 
abdomen  and  trunk.  The  pigmentation  mostly  disappears  after  the  drug  is 
left  off.  Salicylic  acid  or  the  soda  salt  sometimes  gives  rise  to  a  '  measly '  or 
urticarial  rash.     Belladonna  may  produce  a  roseolous  rash  (see  ROSEOLA). 

Tinea  Tonsurans. — Ringworm  of  the  scalp  is  one  of  the  most  trouble- 
some local  diseases  with  which  the  practitioner  has  to  deal,  and  one  which 
is  apt  to  bring  unmerited  discredit  on  account  of  the  many  months  or  even 
years  that  the  disease  sometimes  lasts.  In  some  children  there  seems  to  be 
an  especial  disposition  of  the  disease  to  spread,  and  to  relapse  when  to  all 
appearance  it  has  been  cured,  or,  in  spite  of  the  local  treatment  vigorously 
carried  out  for  months,  no  marked  improvement  ensues  and  every  one  con- 
cerned becomes  tired  of  the  case. 

Ringworm  is  exceedingly  contagious,  one  child  taking  it  from  another  in 
consecjuence  of  the  spores  of  the  tricophyton  being  transferred  from  one  to 
another  by  direct  contact,  or  by  means  of  hair-brushes,  combs,  caps,  or  bed- 
linen  being  used  both  by  the  affected  and  the  healthy.  It  rarely  affects 
infants,  or  children  after  puberty,  its  subjects,  especially  in  the  chronic  form, 
being  the  weakly  rather  than  the  strong,  though  exceptions  may  be  met 
with. 

The  disease  when  recent  may  be  recognised  at  a  glance  :  the  patches  are 
circular,  the  central  skin  in  the  smaller  ones  being  red  in  colour,  while  at 
the  circumference  desquamation  is  freely  going  on,  the  branny  scurf  giving 
the  patch  at  this  part  a  greyish  or  yellowish  appearance  ;  the  hairs  from  the 
central  part  may  have  come  away,  or  they  have  broken  off,  leaving  stumps. 
In  the  larger  patches  all  traces  of  redness  have  disappeared,  and  they  are 
simply  bald  or  scurfy  patches  of  varying  size.  Chronic  diffuse  ringworm  of 
the  scalp,  especially  if  it  has  undei-gone  a  certain  amount  of  irritation  as  the 
result  of  treatment,  is  more  difficult  to  diagnose  ;  there  may  be  much  scurfi- 
ness,  perhaps  scabbing  and  pustulation.  In  the  condition  known  as  kerion 
the  hair  follicles  suppurate,  the  hairs  becoming  loosened  at  their  roots,  and 
there  is  redness  and  puffiness  of  the  patch.  The  diagnosis  of  ringworm  is 
made  from  the  stumps  of  hair  left  after  the  hair  has  broken  off.  These  are 
best  seen  by  means  of  a  lens  of  two  or  three  inches  focal  length:  the  stumps 
will  then  be  readily  seen  often  more  or  less  twisted  or  bent,  and  having  lost 
the  gloss  ordinarily  seen  on  the  hair.  They  are  readily  extracted  with  for- 
ceps, as  they  are  mostly  loose  in  their  follicles  ;  they  can  then  be  placed  upon 
a  glass  slide  with  a  drop  of  licj.  potassa;  and  examined  after  soaking  for  half 
an  hour.  The  broken  hair  will  be  found  to  be  frayed  out  at  the  end,  and 
moreo\er  infiltrated  with  conidia  or  spores  ;  the  latter  are  readily  seen  with 
a  power  of  300  diameters  if  a  sufficient  time  has  been  allowed  for  the  caustic 
alkali  to  dissolve  the  fatty  matters  and  render  the  hair  transparent.     The 


794  Diseases  of  the  Skin 

mycelium  is  less  readily  seen  than  the  spores.  It  is  needless  to  say  it  is 
mostly  useless  to  examine  the  unbroken  hairs,  and  in  old  cases  which  have 
been  treated  no  spores  may  be  present  in  the  scurf.  The  greatest  caution 
must  be  exercised  before  pronouncing  that  a  case  is  well,  or  certifying  that 
it  is  no  longer  infectious,  as  relapses  occur  again  and  again,  and  may  be  the 
means  of  communicating  the  disease  to  others.  Before  any  patient  can  be 
said  to  be  cured,  repeated  examinations  must  be  made  with  the  aid  of  a 
lens  for  diseased  hairs,  any  suspicious-looking  stump  being  extracted  and 
examined  microscopically  ;  it  is  well  to  remember  also  that  scurfy  patches, 
even  when  the  hair  is  growing  freely  over  them,  are  extremely  suspicious. 
In  every  case  some  mild  parasiticide  should  be  continued  to  be  applied  for 
some  time  after  the  disease  appears  to  have  been  eradicated.  In  seborrhoea 
or  non-parasitic  scurfiness  the  whole  scalp  is  affected,  and,  though  the  hair 
may  come  out,  there  are  no  broken  stumps  and  no  sharply  defined  patches 
of  scurfiness  as  in  ringworm. 

The  course  of  ringworm  is  apt  to  be  exceedingly  chronic,  and  when 
undertaking  the  treatment  of  a  case  it  is  well  not  to  be  too  ready  to  name  a 
definite  time  when  it  will  be  well. 

Tinea  Circinata. — Ringworm  of  the  body  is  frequently  associated  with 
ringworm  of  the  scalp.  It  is  first  seen  as  a  raised  red  spot,  which  becomes 
scaly  at  the  periphery  as  it  enlarges,  while  the  centre  may  present  more 
or  less  healthy  skin  ;  as  the  ring  enlarges  it  becomes  more  or  less  broken 
and  fainter.  It  may  be  present  on  all  parts  of  the  body  ;  it  is  perhaps 
commonest  on  the  face  and  neck.  The  diagnosis  is  generally  easy,  for  though 
sometimes  the  patches  of  scurfiness  on  children's  faces  may  be  mistaken 
for  ringworm,  they  do  not  assume  the  formation  of  a  ring  with  a  normal  skin 
in  the  centre  ;  if  any  difficulty  occurs,  an  examination  of  the  scales  scraped 
off  the  patch  for  spores  would  decide. 

Treatment. — The  treatment  of  tinea  circinata  is  a  comparatively  simple 
affair,  and  is  readily  effected  by  the  continuous  application  of  some  mercurial 
ointment  or  solution  for  a  few  days  or  a  week.  It  is  well  to  commence 
treatment  by  removing  the  scales  as  far  as  possible  with  soap  and  water,  and 
then  some  dilute  white  precipitate  ointment  may  be  gently  rubbed  into  the 
patch  morning  and  evening.  An  ointment  containing  sulphur,  5ss,  and  ung. 
picis  liq.,  5j,  to  the  ounce  of  benzoated  lard  also  answers  well.  Carbohc  oil 
or  carbolic  acid  in  glycerine  (i-8)  may  be  used. 

In  the  treatment  of  ringworm  of  the  scalp  the  first  step  to  be  taken  is  to 
cut  the  whole  hair  off  with  a  pair  of  scissors  to  at  least  half  an  inch,  leaving 
a  fringe  if  thought  desirable  ;  the  scalp  can  then  be  carefully  examined,  and 
it  will  be  usually  found  that  there  is  more  extensive  disease  than  was  at  first 
thought.  Wherever  there  are  any  patches  of  ringworm  the  hair  must  be 
cut  close  to  the  scalp  both  over  and  around  the  patch.  The  scalp  should  be 
thoroughly  washed  with  soft  soap  or  carbolic  soap,  removing  all  or  as  many 
of  the  scales  as  possible.  The  ointment  or  application  selected  should  then 
be  rubbed  in  by  means  of  a  mop  of  rag  for  a  few  minutes,  at  least  twice  a 
day.  Very  many  parasiticides  have  been  recommended  ;  the  one  we  have 
mostly  used,  and  which  is  certainly  as  successful  as  any,  is  the  oleate  of 
mercury,  and  we  fully  endorse  Dr.  Alder  Smith's  praises  of  it.  An  oint- 
ment containing  5  per  cent,  is  used  for  children  under  eight  years  of  age,  and 


Treat )iicnt  of  Tijtca  Circinata  795 

lo  per  cent,  for  older  children  ;  a  small  piece  of  the  ointment  is  rubbed 
vigorously  into  the  affected  patch  every  morning  and  evening  ;  if  there  is 
much  tenderness  it  must  be  omitted  for  a  day  or  two.  Once  a  week  at  least 
the  ointment  should  be  washed  off  with  soft  soap,  and  the  effects  of  treat- 
ment carefully  noted.  Oleate  of  mercury  is  especially  suited  for  the  diffuse 
form  of  ringworm  ;  it  apparently  penetrates  better  than  iodine  or  carbolic 
acid,  which  tend  to  harden  the  epithelial  tissues  ;  this  power  of  penetration 
is  obviously  of  great  advantage  when  the  fungus  extensively  affects  the 
hair-roots. 

In  the  early  stages,  when  there  is  a  single  circumscribed  patch  of  ring- 
worm or  only  a  few  patches,  some  more  powerful  remedy  than  the  5  per 
cent,  oleate  of  mercury  may  be  used  with  advantage.  The  10  per  cent, 
ointment  may  be  applied,  or  carbolic  acid  and  glycerine  (1-6  by  measure) 
may  be  rubbed  into  the  patches  night  and  morning.  Coster's  paint  (iodine 
5ij,  oil  of  cade  5'»j)  is  also  useful  in  recent  cases  painted  on  the  patch, 
removing  the  crust  every  few  days  and  re-applying.  Glacial  acetic  acid  and 
iiydrarg.  perchlorid.  (gr.  iv  ad  ^j)  as  used  by  Alder  Smith  are  good  appli- 
cations, as  is  also  Auspitz's  solution  of  chrysarobin  in  chloroform  (F.  1 10). 
The  last  two  must  only  be  used  to  circumscribed  small  patches,  and  are 
not  suitable  for  young  children  or  those  in  whom  inflammation  is  readily 
set  up.  It  is  well  to  keep  the  rest  of  the  scalp  well  oiled  with  carbolic  oil 
when  strong  applications  are  being  applied  to  some  local  patch.  A  light 
skull-cap  should  be  worn  to  prevent  the  ointment  smearing  the  bed  linen  at 
nig-ht. 

While  in  the  chronic  or  diffuse  forms  we  prefer  mercurial  preparations, 
yet  some  cases  appear  benefited  by  a  change,  or  at  any  rate  a  change  of 
ointment  will  sometimes  work  wonders  in  the  eyes  of  the  friends.  An 
ointment  containing  equal  quantities  of  carbolic  acid  (Calvert's  No.  2),  ung. 
hyd.  nitr.,  and  ung.  sulphuris  (Alder  Smith),  is  a  good  and  useful  one  ;  or  the 
formula  (F.  iii)  recommended  by  Jamieson. 

Whatever  form  of  application  is  adopted,  it  is  tolerably  certain  that  much 
patience  will  have  to  be  exercised  before  the  disease  can  be  pronounced 
cured.  Week's  and  e\en  months  may  elapse,  and  while  progress  has  been 
made  perhaps  scurfiness  and  diseased  stumps  can  still  be  detected  ;  or, 
perhaps,  while  the  disease  appears  eradicated  in  one  place,  it  is  spreading  in 
another  direction. 

Epilation  is  useful  in  all  stages,  but  timid  and  young  children  are  too 
nervous  to  submit  to  much  being  done  in  this  way.  In  cases  which  have 
proved  intractable  and  resisted  all  treatment  for  months  a  local  patch  of 
inflammation  may  be  set  up  by  means  of  croton  oil.  The  usual  method  is 
to  paint  some  croton  oil  on  over  a  patch  of  half  an  inch  to  an  inch  in 
diameter,  to  repeat  it  the  next  day,  and  to  follow  it  up  by  a  poultice  ;  the 
patch  becomes  red  and  puffy,  suppuration  takes  place  about  the  hair 
follicles,  and  the  hairs  readily  come  out.  To  this  boggy  condition  the  term 
kerion  is  applied.  It  is  important  to  apply  this  treatment  to  only  small 
patches  at  a  time. 

After  the  disease  has  been  apparently  cured  it  is  well  to  continue  for  a 
time  with  some  remedy  containing  a  mild  parasiticide.  One  of  the  formulae 
106,  108,  or  112  usually  answers  for  this  purpose. 


796  ■     Diseases  of  the  Skin 

Alopecia  Areata.- — Alopecia  consists  of  smooth,  shining  bald  patches  on 
the  scalp.  It  occurs  at  all  ages,  both  of  childhood  and  adult  life.  Its  cause 
is  uncertain,  though  there  is  a  consensus  of  opinion  that  it  isnot  due  to  any 
fungus.  In  some  cases  it  follows  severe  headaches,  in  others  there  is 
no  knowii  cause,  though  it  occurs  mostly  in  those  who  are  below  par  and 
out  of  health.  It  may  occur  first  in  patches,  and  perhaps  after  a  while 
involve  the  whole  scalp.  It  is  extremely  intractable,  and  little  influenced  by 
local  or  constitutional  treatment.  Cod-liver  oil  and  tonics  are  usually  given, 
and  stimulating  lotions,  such  as  F.  114. 

Favus. — Favus  is  not  a  common  disease  in  this  country,  but  is  occasion- 
ally seen  among  out-patients  at  a  children's  hospital.  It  is  known  at  once 
by  the  peculiar  yellow  cup-like  depressions  formed  by  the  crusts,  and  by  the 
peculiar  '  mousy  '  smell.  These  crusts  can  be  raised  from  the  scalp  by  means 
of  a  blunt  knife,  carrying  the  hairs  with  them,  leaving  the  pitted  skin,  which, 
however,  crusts  over  again  in  ten  or  twelve  days.  The  favus  crusts  may  be 
present  on  the  body  as  well  as  on  the  scalp.  The  subjects  of  this  disease  are 
generally  cachectic  and  have  been  ill  fed.  The  fungus — achorion  Schonleinii 
— closely  resembles  the  tricophyton  of  ringworm,  but  the  mycelium  is  more 
jointed,  and  the  gonidia  are  more  numerous  and  larger,  though  they  vary 
much  in  size. 

The  disease  is  very  chronic,  frequently  lasting  for  years.  The  treatment 
consists  in  removing  the  crusts,  applying  parasiticides,  and  administering 
cod-liver  oil  and  iron. 

Scabies, — Scabies  is  very  common  in  infants  and  children  in  dispensary 
practice,  and  by  no  means  unknown  among  the  well-to-do  classes  of  society. 
Among  the  former  there  is  rarely  any  difficulty  in  diagnosis,  as  they  usually 
do  not  present  themselves  till  the  disease  is  well  marked  and  pustules  have 
formed,  while  in  private  practice  the  diagnosis  may  be  difficult  when  the  disease 
is  local,  as,  for  instance,  on  the  hands.  In  infants  and  young  children  scabies 
gives  rise  to  more  irritation  than  in  adults,  and  in  infants  at  the  breast  urticaria 
and  erythema  of  a  more  or  less  severe  nature  may  be  frequently  seen.  In 
infants  the  hands  may  be  quite  free,  while  the  face  and  legs  or  genitals  may 
be  affected.  In  cachectic  or  weakly  children  there  are  usually  much  crusting 
and  many  pustules,  pus  being  transferred  from  one  part  to  another  by 
means  of  the  finger-nails.  The  diagnosis  is  not  usually  difficult  ;  urticaria, 
simple  eczema,  and  lichenous  rashes  may  be  mistaken  for  it.  The  presence  of 
burrows,  the  irregular  distribution  of  the  vesicles  and  papules,  as  well  as  the 
intense  itching,  are  the  characteristic  points.  We  have,  however,  sometimes 
been  in  doubt  regarding  the  nature  of  itching  rashes  present  only  on  the 
backs  of  the  hands.  A  cure  is  readily  effected  by  a  hot  bath  with  the  copious 
use  of  soft  soap,  followed  by  sulphur  or  storax  ointment ;  the  bath  and 
ointment  should  be  repeated  for  four  or  five  nights  in  succession,  and  the 
clothes  should  be  stoved.     (F.  115,  116,  117.) 

Pediculosis. — The  pediculus  capitis  is  exceedingly  common  among  the 
children  of  the  poorer  classes,  and  is  by  no  means  unknown  in  other 
cjuarters.  The  insect's  bite  produces  intense  itching  of  the  scalp,  more 
especially  in  the  occipital  region,  and  vigorous  scratching  takes  place.  As 
a  result,  more  especially  in  the  weakly  and  cachectic,  scabs,  crusts,  and 
pustules  form,  and  in  many  cases  the  occipital  glands  become  enlarged  and 


Pediculosis  797 

may  suppurate.  A  diagnosis  is  readily  made,  by  the  presence  of  nits  and 
also  crusts  and  scabs  in  the  occipital  region.  The  hair  should  be  cut  short, 
the  scalp  thoroughly  cleansed  with  hot  water  and  carbolic  soap,  and  white 
precipitate  ointment  applied.  Liquid  paraffin  or  spirits  of  wine  are  \ery 
efficacious,  but  the  smell  is  disagreeable. 

Flea-bites. — The  common  flea  produces  by  its  bite  a  small  wheal 
surrounded  by  a  red  area,  with  a  central  red  spot.  The  central  spot,  as 
also  the  distribution  of  the  eruption,  will  generally  distinguish  it  from 
urticaria  or  other  rashes.  The  bite  in  debilitated  subjects  becomes  petechial. 
The  itching  and  irritation  produced  by  flea-bites  cause  great  restlessness  and 
fever  at  night.  vSome  children  are  much  more  affected  by  flea-bites  than 
others.  Body-lice  and  bugs  produce  similar  eruptions.  Carbolic  ointment 
(ten  per  cent.),  lead  and  carbolic  lotion,  or  diluted  sp.  amnion,  aromat.  are 
useful  in  allaying  irritation. 

Midg-e-bites. — Midges  mostly  attack  the  exposed  parts,  such  as  the  face, 
arms,  and  legs.  They  will,  however,  crawl  up  arm  slieves,  beneath  the 
stockings  and  up  the  legs.  In  hot  weather  especially  their  bites  give  rise  to 
large  wheals,  which  may  become  vesicular  or  pustular.  The  irritation  is 
worse  at  night,  and  much  scratching  takes  place.  If  pustules  follow  the 
bites,  an  auto-infection  perhaps  takes  place,  and  pustules  make  their 
appearance  in  various  parts  of  the  body.  We  have  seen  children  on  their 
return  from  their  summer  holidays  with  deep  ulcers,  pustules,  and  enlarged 
glands,  the  result  of  midge-bites. 

Harvest  bug-. — Occasionally  during  holidays  in  the  country  children 
will  suffer  from  the  attacks  of  the  'harvest  bug'  (Leptus  autumnalis).  To 
the  naked  eye  it  is  a  small  red  point,  which  adheres  to  the  skin  and  produces 
papules  that  itch  greatly.  It  buries  its  head  in  the  skin,  and  in  this  way 
produces  great  irritation.  It  may  produce  symptoms  not  unlike  scabies,  the 
feet  and  legs  being  first  affected.  Pustules,  ulcers,  and  staphylococcia 
may  result.     A  weak  sulphur  or  mercurial  ointment  may  be  used. 

Simple  Onychia  in  children  may  be  looked  upon  as  a  variety  of  the 
subcuticular  form  of  whitlow,  in  which  the  nail  matrix  is  involved  instead  of 
the  skin  of  the  finger.  If  is  usually  the  i-esult  of  some  slight  injury  such 
as  nail-biting,  running  a  splinter  beneath  the  nail,  or  too  close  cutting 
of  the  nails.  Early  letting  out  of  the  matter  and  removal  of  foreign  material, 
with  subsequent  warm  water  or  lead  lotion  dressing,  is  all  that  is  required. 
Occasionally  suppuration  goes  on  intractably  beneath  the  nail,  or  recurs 
again  and  again  after  drying  up  ;  in  such  cases  the  nail  should  be  cut  away 
over  the  inflamed  spot,  and  the  surface  scraped  clean,  and  some  solid  nitrate 
of  silver  applied. 

Onychia  Maligna  is  a  moi'e  formidable  affection,  nearly,  if  not  quite, 
always  due  to  injury  of  the  finger-end.  The  whole  nail  matrix  becomes 
inflamed,  the  end  of  the  finger  is  swollen,  congested,  and  bulbous,  the  nail 
becomes  loosened,  curled  up,  and  blackened,  and  there  is  much  burning  pain  ; 
a  dirty,  sero-sanguineous,  often  foul  discharge  comes  away,  and  the  mischief 
may  go  on  for  months  if  neglected,  and  even  give  rise  to  necrosis  of  the 
terminal  phalanx  and  permanent  distortion  or  destruction  of  the  nail.  The 
treatment  we  have  hardly  ever  found  to  fail  is  dusting  the  raw  surface  o\er 
with  powdered  nitrate  of  lead  night  and  morning  for  a  few  days  ;  the  nail 


798 


Diseases  of  the  Skin 


should  be  removed  if  the  disease  has  involved  anything  more  than  the  upper 
part  of  the  matrix.  We  have  often  seen  onychia  of  many  months'  standing 
get  practically  well  in  a  week  under  this  treatment.  Occasionally  it  is  neces- 
sary to  scrape  away  the  diseased  tissue  and  remove  a  sequestrum,  but  this  is 
quite  exceptional. 

Iiupus. — Mention  has  already  been  made  of  superficial  tuberculous 
ulceration  of  the  skin  {vide  p.  241),  but  the  special  form  known  as  lupus 
vulgaris  needs  a  short  notice  here.  The  affection  consists  in  the  develop- 
ment of  small  circular  deposits  of  inflammatory  material  in  the  thickness 
of  the  true  skin.  These  deposits,  known  as  '  lupus  tubercles,'  are  found 
usually  in  patches  which  tend  to  spread  by  the  formation  of  new  tubercles  at 
the  margin  of  the  patch.  At  first  isolated,  after  a  while  the  tubercles 
coalesce  and  break  down,  forming  a  larger  or  smaller  superficially  ulcerated 
patch,  which  is  usually  coated  over  with  thick  scabs  or  crusts.  In  earlier 
stages  there  is  no  obvious  ulceration,  and  a  thin  pellicle  covers  over  each 
'  tubercle.'  If  allowed  to  spread,  extensive  destruction  of  the  skin  may 
occur,  and  the  deeper  structures  are  in  certain  cases  attacked.  It  is,  how- 
ever, very  rare  for  lupus  to  penetrate  through 
the  deep  fascia,  and  it  probably  never  attacks 
bone.  The  most  extensive  destruction  is  usu- 
ally of  the  nose,  where  the  whole  of  the  lateral 
and  alar  cartilages  may  be  eaten  away,  leaving 
a  short,  pinched,  and  shrunken  organ.  Almost 
any  part  of  the  body  may  be  attacked,  but  the 
face  is  the  favourite  seat,  and  especially  the 
tip  and  sides  of  the  nose.  Less  often  the 
disease  attacks  the  mucous  membrane  of  the 
lips,  cheeks,  and  septum  nasi,  and  we  have 
seen  the  tonsil  and  soft  palate  involved  by 
extension  from  a  patch  of  lupus  at  the  angle 
of  the  mouth.  We  have  one  case  under  our 
care  in  which  the  skin  of  the  shoulder,  arm, 
and  also  the  buttock  and  thighs,  is  extensively 
involved.  The  disease  has  lasted  some  years.  Chronic  in  its  course,  and 
intractable  to  any  but  very  thorough  treatment,  lupus  is  one  of  the  most 
troublesome  of  the  skin  diseases  met  with  in  tuberculous  subjects,  especially 
as  great  deformity  and  disfigurement  are  often  produced  by  its  ravages. 
On  scraping  out  a  '  lupus  tubercle '  a  hollow  or  pit  is  seen  in  the  thickness 
of  the  dermis,  while  at  the  edge  of  the  patch  the  superficial  part  of  the  skin 
is  undermined. 

Treatment. — The  general  treatment  is  that  of  tuberculosis,  cod-liver  oil 
and  arsenic  being  of  especial  value.  Locally  nothing  is  so  effectual  as 
thorough  removal  of  the  disease  mechanically.  It  is  best  to  give  an 
anaesthetic,  and  thoroughly  scrape  away  and  dig  out  all  the  soft  tissue  with  a 
sharp  spoon.  All  the  material  that  can  be  scraped  away  should  be  removed  ; 
healthy  skin  will  not  break  down  under  the  use  of  a  Volkmann's  spoon. 
After  the  scraping  the  actual  cautery  or  solid  nitrate  of  silver,  or,  better  still, 
powdered  nitrate  of  lead,  may  be  applied,  but  the  mechanical  removal  is  the 
most  important  part  of  the  process.     There  is  free  bleeding  at  the  time,  but 


Fii 


206. — Hairy  mole  of  the  face 
and  scalp.  A  large  part  of  the 
patch  was  removed  by  the  use  of 
the  actual  cautery  and  nitric  acid. 


Hairy  and  Pigmented  Moles  799 

this  speedily  stops.  The  sore  should  be  dressed  with  iodoform  ointment,  and 
;v  careful  watch  kept  for  the  appearance  of  fresh  tubercles,  which  should  lae  at 
once  attacked  in  the  same  way.  The  repeated  application  of  powdered 
nitrate  of  lead  has  been  very  useful  in  our  hands,  both  for  lupus  and  other 
intractable  tuberculous  sores  ;  it  is  somewhat  painful,  but  very  effective. 
Injections  of  tuberculin  have  recently  been  employed  with  some  success. 
Certainly  in  many  cases  there  is  a  temporary  improvement,  but  relapses  are 
very  apt  to  occur. 

Papilloma. — Warts  are  very  commonly  met  with  on  children's  hands, 
and  often  appear  in  crops.  They  frequently  disappear  spontaneously,  but  if 
they  are  troublesome  may  be  readily  cured  by  some  caustic  application,  or 
better  by  the  steady  use  of  salicylic  collodion. 

Hairy  and  Pigmented  IVXoles  occur  congenitally,  and  sometimes  cause 
great  disfigurement,  as  in  fig.  206.  If  small  they  may  be  treated  by  excision. 
If  extensive  the  growth  may  be  removed  in  sections  by  the  application  of 
the  actual  cautery  or  strong  nitric  acid,  but  it  must  be  remembered  that  any 
of  these  methods  necessarily  leave  a  scar.  Mei^e  overgrowth  of  hair  may 
be  removed  by  electrolysis  and  epilation. 


8oo  Injuries,  Shock,  Hceniorrhage,  &c. 


CHAPTER   XXXIX 

INJURIES,    SHOCK,    HAEMORRHAGE,    &C. 

The  various  injuries  met  with  in  children  can  only  be  very  briefly  described 
here,  and  only  those  more  or  less  peculiar  to  childhood  will  be  mentioned. 

Injuries  to  the  Head. — ^In  young  children  it  is  not  uncommon  for  one 
of  the  bones  of  the  vault  of  the  skull  to  be  dinted  or  dinged  in,  and  a  well- 
marked  but  shallow  saucer-like  depression  may  be  felt.  Care  must  be  taken 
to  distinguish  this  lesion  from  cephalhcematoma  {z'ide  p.  21).  The  symptoms 
of  brain  injury  in  such  a  case  are  usually  those  of  concussion  and  often 
speedily  pass  off ;  recovery  usually  takes  place  without  any  bad  symptoms, 
and  the  depression  in  most  instances  gradually  becomes  obliterated  by 
pressure  from  within  and  modelling  of  the  bone. 

The  treatment  of  such  cases  is  simply  rest  and  quiet  ;  no  operation  is 
called  for.  Sometimes,  however,  where  the  depression  is  more  abrupt  and 
marked  symptoms  of  compression  exist,  especially  if  the  fracture  is  com- 
pound, the  general  lines  of  treatment  for  such  cases  in  adults  must  be 
followed.  In  children  the  rule,  however,  is  not  to  operate  unless  the  fracture 
is  compound. 

Traumatic  Cephalhydrocele  is  the  name  applied  to  a  condition  where 
there  has  been  a  simple  fracture  of  the  skull,  with  probably  in  all  cases 
laceration  of  brain  and  laying  open  of  one  or  other  lateral  ventricle.  The 
fluid  contained  in  the  ventricle  escapes  beneath  the  scalp  and  forms  a  soft, 
fluctuating,  usually  pulsating  swelling  ;  this  is  distinguished  from  hematoma 
in  some  cases  by  its  later  onset  and  steady  increase.  The  swelling,  how- 
ever, may  appear  immediately  ;  sometimes  it  is  not  found  for  some  months 
after  the  injury  ;  in  any  doubtful  case  aspiration  would  settle  the  point. 

Cephalhydrocele  is  most  often  met  with  in  children  under  two  years  old, 
but  may  occur  as  late  as  the  twelfth  year  ;  it  is  most  common  in  the  parietal 
region.  We  have  seen  several  of  these  cases.  There  is  often  extensive 
absorption  of  bone  after  the  injury,  so  that  a  considerable  gap  is  left  in  the 
skull.     Hydrocephalus  not  rarely  ensues. 

Treatment,  &^c. — Tapping  appears  to  be  of  little  use,^  and  pressure  and 
quiet  are  the  only  treatment.  A  plastic  operation  has  been  proposed  to  close 
the  aperture  in  the  skull,  and  might  possibly  be  advisable  in  any  case  that  was 
clearly  getting  worse. 

The  mortality  is  high  :  some  40  per  cent,  of  the  patients  die  ;  in  some 
instances  temporary  recovery  takes  place  and  meningitis  develops  later. 

1  Lucas,  Guy's  Refts.  1879  et  seq.  ;  T.  Smith,  St.  Bartk.'s  Repts.  1884.  Erichsen, 
Southam,  Godlee,  Howard,  and  Conner  have  recorded  cases  ;  also  Golding  Bird,  Guy's 
Repts.  1889.      Year  Booli  of  Treatmefit,  1895,  p.  226. 


Injuries  of  the  Chest,  Abdomen,  &c.  80 1 

Occasionally  after  compound  fracture  of  the  vault  a  free  escape  of 
similar  fluid  occurs,  as  in  one  case  of  our  own  :  there  was  a  compound  de- 
pressed fracture  of  the  frontal  bone,  which  required  elevation  ;  an  abundant 
flow  of  clear  fluid  took  place  from  the  wound  before  operation  ;  the  boy 
recovered  without  any  bad  symptom. 

Fracture  of  the  Base  of  the  Skull  in  children  is  a  much  less  serious 
injury  than  in  adults,  and  is  often  completely  recovered  from.  Traumatic 
meningitis  is  rare  in  children,  and  they  generally  recover  well  from  con- 
cussion and  brain  laceration. 

Dr.  Allen  ('  Lancet,'  October  24,  1885;  has  descriljed  a  fracture  disloca- 
tion of  the  atlas  occurring  in  infants  ;  the  lesion  is  marked  by  hyper-extension 
of  the  head  and  a  liability  to  '  epileptic  fits '  on  attempts  at  extension  or 
pressure  downwards  upon  the  head.  The  injury  is  probably  inflicted  during 
parturition.      Vide  ■2\'~,o  Guerin,  '  Gaz.  Medic.,'  185 1. 

Injuries  of  the  Chest. — The  only  fact  about  chest  injuries  that  is 
peculiar  to  childhood  is  that,  in  consequence  of  the  flexibility  of  the  chest - 
wall,  visceral  lesions  without  fracture  of  the  ribs  are  not  uncommon.  When 
rupture  of  the  lung  occurs  the  laceration  is  usually  in  the  neighbourhood  of 
the  root  of  the  lung,  and  the  usual  complications — emphysema,  hasmothorax, 
and  htfmoptysis — are  often  present,  though  the  last  is  less  often  seen,  since 
young  children  rarely  expectorate,  and  the  blood  is  swallowed. 

Injuries  of  the  Abdomen  have  no  peculiar  features  ;  if  the  immediate 
shock  is  recovered  from,  subsequent  complications  are  rarely  fatal  unless 
from  some  severe  visceral  laceration. 

Fracture  of  the  pelvis  in  childhood  is  less  likely  to  be  complicated  by 
visceral  injuries  than  in  adults,  since  sub-periosteal  fractures  and  separation 
of  epiphyses  take  place  in  children.  We  have  met  with  a  case  of  fractured 
pelvis  in  which  the  urethra  was  separated  from  its  normal  position  beneath 
the  pubic  arch  and  displaced  backwards  towards  the  anus,  the  injury 
occurring  in  a  little  girl. 

Rupture  of  the  membranous  or  spongy  urethra  is  not  uncommonly  met 
with  in  boys  as  a  result  of  failing  astride  some  projecting  edge,  e.g.  the  top 
of  palings  or  pf  a  gate,  or  the  bough  of  a  tree.  The  symptoms  are  pain  and 
swelling  in  the  periniEum,  escape  of  blood  from  the  urethra,  inability  to  pass 
urine,  and  distension  of  the  bladder  unless  it  has  been  recently  emptied. 
A  gentle  attempt  should  at  once  be  made  to  pass  a  catheter  ;  if  this  succeeds, 
the  instrument  should  be  tied  in  for  three  or  four  days  and  then  changed  ; 
after  a  week  or  ten  days  it  is  sufficient  to  pass  a  full-sized  catheter  daily. 
This  is  the  orthodox  treatment,  but  a  traumatic  stricture  usually  results, 
requiring  the  passage  of  instruments  frequently  throughout  life.  Extravasa- 
tion of  urine  often  occurs  either  immediately  or  within  a  day  or  two  of  the 
accident,  and  necessitates  free  incisions  into  all  the  infiltrated  parts.  To 
avoid  these  misfortunes  probably  the  best  plan  is,  immediately  after  the 
accident,  to  cut  down  upon  and  suture  together  the  ends  of  the  torn  urethra. 
This  we  have  done  with  excellent  results  in  adults,  and,  as  a  secondary 
operation,  in  a  child. 

Injuries  of  the  Iiimbs. — The  peculiarities  of  injuries  to  the  limb  bones 
in  children  depend  mainly  upon  two  facts,  i.  The  bones  of  children  are 
soft,    contain  relatively   little  earthy  matter,  and  are  therefore  less  brittle 

■\  F 


8o2  Injuries,  Shock,  Hcsmorrhage,  &c. 

than  those  of  adults.  2.  The  epiphyses  are  yet  ununited,  and  the  periosteum 
is  thicker,  more  easily  detached,  and  more  freely  supplied  with  blood  than 
in  older  people. 

Greenstick  Fractures. — A  greenstick  fracture  is  one  where  more  or 
less  of  the  thickness  of  a  bone  has  bent  and  yielded  instead  of  snapping 
across  ;  there  is  probably  really  always  a  fracture.  Simple  bending  of  bone 
without  fracture  is  of  doubtful  occurrence,  in  health  at  least,  though  it  may 
occur  in  rickets  and  osteomalacia.  Many  fractures  in  children  are  sub- 
periosteal, and  to  this  fact  and  to  the  incompleteness  of  the  fracture  is  due 
the  absence  of  marked  symptoms  in  many  cases,  so  that  fractures  are  not 
rarely  overlooked  ;  indeed,  deformity,  obvious  mobility,  and  crepitus  may 
all  be  absent,  and  it  is  common  enough  to  see  a  fractured  clavicle  of  a 
week's  or  a  fortnight's  standing,  or  even  longer,  in  which  the  first  sign  that 
attracted  the  parent's  attention  was  the  '  lump  in  the  neck,'  consisting  of 
callus  round  the  fractured  ends.  Hence,  after  any  severe  injury,  each  part  and 
limb  should  be  systematically  searched,  especially  in  very  young  children, 
for  all  probable  injuries.  The  treatment  of  greenstick  fractures  is  the  same 
as  for  ordinary  fractures,  any  displacement  being  at  once  forcibly  reduced. 

ITnunited  Fractures. — Fractures  in  children  usually  unite  well,  and  even 
in  rickety  patients  non-union  is  rare.  We  have  already  mentioned  cases  of 
non-union  in  fracture  after  necrosis  of  the  tibia  and  humerus.  Occasionally 
one  or  more  of  the  long  bones  is  fractured  at  or  shortly  after  birth,  or  even 
in  utero,  and  in  these  cases  non-union  is  not  very  rarely  met  with.  It  is  a 
curious  fact  that  such  fractures  have  almost  universally  resisted  all  attempts 
to  procure  union  when  once  the  ends  of  the  bones  have  become  atrophied 
and  a  false  joint  has  formed.  Sir  James  Paget  has  pointed  out  this  pecu- 
liarity.^ In  one  of  our  patients  we  tried  many  methods  before  obtaining 
union,  as  will  be  seen  below. 

Case. — John  H.,  at  six  weeks  old,  was  found  to  have  a  fracture  of  the  leg,  but  it  was 
not  known  how  long  it  had  existed.  The  mother  had  a  fall  two  months  before  he  was 
born.  On  admission  there  was  an  old  ununited  fracture  of  both  bones  of  the  right  leg 
I5  inch  above  the  ankle  ;  the  limb  was  loose  and  almost  flail-like.  In  May  1889  the 
ends  of  the  bones  were  resected,  and  the  tibia  wired ;  no  union  followed.  He  was  re- 
admitted in  July  and  plaster  of  Paris  re-applied.  In  October  the  ends,  which  were  much 
atrophied,  were  again  resected,  and  ten  pieces  of  bone,  taken  from  the  femur  of  a  freshly 
killed  young  rabbit,  were  grafted  in.  The  wound  healed  by  primary  union,  and  the  limb 
was  put  up  in  plaster.  No  union  nor  even  any  formation  of  callus  followed.  In  January 
1890  the  operation  was  repeated  ;  eight  grafts  being  inserted,  the  wound  was  closed  and 
the  limb  put  up  in  plaster.  Three  pieces  of  the  rabbit's  bone  were  removed  in  April  and 
May,  and  the  wound  healed.  In  June  the  wound  was  re-opened,  and  a  long  piece  of  rabbit's 
femur  wedged  in  between  the  ends.  The  wound  healed  at  once,  and  a  good  deal  of  thick- 
ening, but  no  real  tmion,  followed.  In  April  1891  the  wound  was  re-opened  and  the  large 
piece  of  rabbit's  bone  found  bare  and  encysted  in  a  cavity  containing  clear  yellow  fluid  ; 
smaller  pieces  were  found  embedded  in  fibrous  tissue ;  there  was  no  sign  of  any  septic 
condition.  The  rabbit's  bone  was  removed  and  the  ends  of  the  tibia  freshened  ;  an  inch 
of  the  fibula  of  the  same  leg  was  then  taken  from  just  below  its  head  and  fitted  in  between 
the  ends  of  the  tibia.  No  union  followed,  and  in  September  1891  the  ends  were  again 
resected,  and  stout  steel  pins  driven  crosswise  through  the  fragments,  which,  b)'  reason  of 
the  shortening  of  the  fibula,  could  be  brought  well  into  apposition.  Round  the  ends  of 
the  pins  silver  wire  was  wrapped  as  in  a  harelip  suture  ;  the  wound  was  closed  and  the 

^  Studies  from  Old  Case  Books,  1891. 


Separation  of  the  Epiphyses  803 

limbs  fixed  in  plaster.  In  Uecenilier  1891  the  plaster  was  removed,  and  the  bones  were 
found  united  ;  one  of  the  pins  was  removed  and  the  limb  fixed  in  plaster  of  Paris.  The 
union  was  firm  when  the  limb  was  examined  in  August  1892,  and  the  wound  was  quite 
sound,  but  the  limb  was  still  weak,  and  no  restoration  of  the  fibula  had  taken  place. 
D'Arey  Power  has  collected  a  series  of  72  cases  ;  in  45  of  these,  attempts  to  obtain  union 
failed.     ('Med.  Chir.  Trans.,'  vol.  Ixxv.) 

Separation  of  Epiphyses. — Since  the  last  edition  of  this  book  Mr. 
Poland's  fine  work  on  '  Traumatic  Separation  of  the  Epiphyses '  has  appeared, 
and  to  it  all  who  require  a  full  account  of  these  injuries  must  refer.  A  valuable 
series  of  papers  on  fractures  of  the  upper  extremity  by  Mr.  Piatt  has  also 
been  recently  (1898-99)  published  in  the  '  Medical  Chronicle.'  Papers  also  by 
J.  Hutchinson,  jun.,  and  his  annotations  in  Helferich's  work  may  be  consulted. 
The  discovery  and  development  of  radiography  has  of  course  enabled  great 
additions  to  be  made  to  our  knowledge  of  these  injuries.  A  pure  epiphysial 
separation  is  met  with  commonly  in  certain  bones,  as  in  the  case  of  the  lower 
end  of  the  radius  (Plates  X.  and  XL),  the  upper  end  of  the  humerus,  and  the 
lower  end  of  the  femur  (J.  Hutchinson,  jun.).  In  many  cases,  however, 
and  sometimes  in  those  mentioned,  the  injury  is  a  combination  of  fracture 
and  diastasis  (see  Plates  VI.  and  XII.)  ;  that  is,  the  line  of  separation  runs 
partly  through  cartilage  and  partly  through  bone.  The  periosteum  in  many 
of  these  cases  remains  untorn,  and,  as  Mr.  Hutchinson  has  shown,  it  is  in 
many  instances  extensively  stripped  up  from  the  diaphysis,  and  necrosis  may 
follow.  Hence  the  symptoms  of  epiphysial  separation  or  diastasis  vary  con- 
siderably; thus  there  may  be  little  or  no  displacement,  crepitus  may  be  absent, 
or  very  indistinct  ;  and  undue  mobility  may  be  only  recognisable  on  very 
careful  manipulation.  We  have  seen  many  cases  in  which  there  has  been 
a  history  of  previous  injury,  supposed  to  be  a  strain,  in  which  the  amount  of 
thickening  found  at  the  time  of  examination  makes  it  almost  certain  that  a 
more  or  less  complete  separation  of  an  epiphysis  had  occurred.  This  is  espe- 
cially common  about  the  lower  end  of  the  humerus,  and  our  experience  fully 
bears  out  Mr.  Hutchinson's  statement  that  these  accidents  are  exceedingly 
common,  and  in  any  doubtful  case  of  injury  about  the  elbow  they  should 
always  be  suspected.  Curiously,  Hamilton  ('  Fractures  and  Dislocations  ') 
says  he  has  never  met  with  a  case.  It  is,  however,  possible  that  in  some 
instances  the  violence  may  strip  up  muscles  and  the  thick  loose  periosteum 
without  any  fracture  or  diastasis,  and  this  injury  of  the  periosteum  may  be 
the  cause  of  the  subsequent  thickening. 

In  well-marked  cases  there  are  deformity,  undue  mobility,  loss  of  power, 
and  sometimes  indistinct  or  so-called  'false' or 'dummy' crepitus  ;  the  outlines 
of  the  fragments  are  more  rounded  than  in  ordinary  fracture,  and  the  line  of 
separation  coincides  with  that  of  an  epiphysis.  It  must  be  remembered  that 
an  epiphysial  junction  is  not  a  flat,  plane  surface,  but  there  is  in  many  of  the 
bones  a  cup-shaped  hollow  in  the  epiphysis  which  receives  the  rounded  con- 
vex end  of  the  shaft.  It  is  often  difficult  to  reduce  and  keep  in^  place  the 
fragments,  and  a  certain  amount  of  deformity  is  often  persistent,  though  this 
diminishes  by  a  gradual  process  of  modelling  as  time  goes  on.  Arrest  of 
growth  occurs  in  some  cases,  not  in  others  ;  probably  this  depends  upon  the 
accuracy  with  which  the  lesion  has  followed  the  epiphysial  line,  and  the 
amount  of  destruction  of  the  growing  bone  or  of  premature  synostosis  that 

3  F  2 


8o4 


Injuries,  Shock,  Hceniorrhage,  &c. 


results.  Occasionally  acute  necrosis  of  a  separated  epiphysis  occurs,  or  at 
least  acute  suppuration  around  it,  and  this  is  said  to  be  disproportionately 
frequent  in  cases  of  separation  of  the  epiphysis  of  the  great  trochanter  and 
lower  end  of  femur.  (Hutchinson,  junior.)  These  injuries  are  most  common 
about  the  two  ends  of  the  humerus,  the  lower  end  of  the  radius,  and  the 
lower  end  of  the  femur.  It  is  sometimes  said  that  separation  of  the  lower 
end  of  the  femur  is  the  most  frequent  accident,  but  in  our  experience  it  is 
not  nearly  so  common  as  the  diastasis  of  the  humerus.     We  have  once  met 

with  diastasis  of  the  upper 
femoral  epiphysis  {vide  'Hip 
Disease  in  Childhood,'  by  one  of 
the  present  writers)  and  ^  which 
possibly  (Plate  XIV.)  may  have 
been  a  case  of  diastasis  and  frac- 
ture combined.  Poland  has  col- 
lected a  number  of  instances. 
Occasionally  diastases  are  met 
with  at  the  upper  end  of  the 
tibia.-  Tubby  -^  has  collected 
cases  of  separation  of  the 
clavicular  epiphysis.  The  dia- 
gnosis depends  upon  the  age  of 
the  patient,  the  fact  that  the 
projecting  edge  of  the  bone  is 
sharp  and  unlike  the  natui-al 
inner  end  of  the  clavicle,  as  it 
would  be  in  the  case  of  a  dislo- 
cation, and  also  in  that  a 
lamella  of  bone  can  be  felt  be- 
tween the  sternal  notch  and  the 
end  of  the  shaft.  It  must  be 
remembered  that  the  epiphysis 
is  only  an  extremely  thin 
plate.  We  have  lately  met  with 
an  instance  of  this  injury. 

According  to  Tubby,  separa- 
tion of  the  coracoid  epiphysis  is 
of  extreme  rarity,  and  no  case 


■  Separation  of  the  Upper  Epiphysis  of  the 
Right  Humerus. 


of  separation  of  the  acromial  epiphysis  appears  to  be  authentic. 

Diastasis  of  the  upper  end  of  the  humerus  is  not  rarely  met  with.     It 
results    from   injuries  such  as  blows  or  falls  upon  the  arm,  which,  in  the 


^  See  also  Stimson  on  Fractures,  and  Hutchinson,  Arch,  of  Surgery,  April  1892,  and 
Tubby,  A/mals  of  Surgery,  1894,  vol.  xix. 

-  Separation  of  the  upper  epiphysis  of  the  tibia  has  been  caused  by  the  bad  practice  of 
applying  extension  for  hip  disease  below  the  knee  instead  of  above  it. 

•''  Guy's  Reports,  1889. 

Note. — For  an  account  of  separation  of  epiphyses  due  to  congenital  syphilis  (syphilitic 
telostitis)  vide  chapters  on  'Congenital  Syphilis'  and  on  'Bone  Diseases.'  Similar 
multiple  separations  may  be  the  result  of  so-called  '  scurvy  rickets.' 


Separation  of  tJic  Epiphyses 


805 


adult,  would  probably  cause  either  fracture  of  the  shaft  or  dislocation  of  the 
shoulder.  It  appears  to  be  not  uncommonly  the  result  of  injury  at  birth. 
The  appearance  of  the  shoulder  is  characteristic,  though  much  like  that  of 
fracture  of  the  surgical  neck  of  the  bone.  There  is  no  depression  below  the 
acromion,  but  some  flattening  a  little  lower  down,  with  a  marked  prominence 
on  the  anterior  and  inner  aspect  of  the  arm,  a  short  distance  below  the  cora- 
coid  process.  This  prominence  is  the  upper  end  of  the  shaft  of  the  humerus 
displaced  forwards  and  inwards  ;  the  edges  of  the  projecting  bone  are  more 
rounded,    and    less    sharp    and 

Epiphyses  of  Head  fc 

Tuherosities  llenil  at 

6  '^  y?  and  icuitp 


irregular  than  in  the  case  of  frac- 
tured surgical  neck,  and  on  re- 
duction, which  is  usually,  though 
with  difficulty,  managed, 'dummy' 
crepitus  instead  of  that  of  a  true 
fracture  is  felt.  It  is  difficult 
to  keep  the  fragments  in  posi- 
tion, but,  as  the  surfaces  are 
broad,  there  is  very  rarely  or 
never  any  actual  overlapping. 
Since  the  upper  epiphysis  of  the 
humerus  includes  the  tuberosities, 
there  is  abundant  blood  supply 
to  the  upper  fragment,  and  union 
usually  takes  place  speedily. 
The  treatment  consists. in  apply- 
ing a  long  inside  angular  splint, 
well  padded  at  the  top  and  fitting 
high  up  into  the  axilla.  The 
fragments  are  brought  into  posi- 
tion, and  a  felt  or  gutta-percha 
shoulder-cap  is  then  moulded  on. 
Gentle  actiye  movement  should 
be  begun  In  ten  days.  The 
deformity  is  rarely  entirely  re- 
duced, but  good  union  and  a 
useful  though  possibly  somewhat 
shortened  limb  results.  If  the 
displacement  is  considerable  and 
cannot  be  reduced,  operation  is 
justifiable  to  correct  it.  The 
injury  may  be  compound  or  complicated  with  rupture  of  the  axillary  artery. 
We  have  wired  one  case  of  compound  separation  with  a  good  result.  Instances 
of  non-union  have  been  met  with,  and  shortening  to  the  extent  of  five  inches 
ten  years  after  the  injury. 

Separation  of  the  lower  epiphysis  of  the  humerus  is,  we  think,  far  the 
commonest  lesion  of  the  kind  met  with  in  children.  It  is  very  common  to 
have  children  brought  with  an  injury  to  the  elbow  of  some  days'  duration, 
and  a  statement  that  the  limb  has  been  strained  or  the  joint  put  out.  On 
examination  there  is  pain  and  restricted  movement  about  the  elbow  joint,  but 


Unites  with 
Shaft  at 


Fig.  208. — Plan  of  the  Development  of  the  Humeru.s. 
By  Seven  Centres.     From  Gray's  '  Anatomy.' 


8o6 


Injuries,  Shock,  Hcemorrhage,  &c. 


the  olecranon,  the  head  of  the  radius,  and  the  internal  condyle  occupy  their 
normal  relations  to  one  another.  On  grasping  the  lower  end  of  the  humerus 
between  the  finger  and  thumb,  marked  thickening  as  compared  with  the  other 
side  is  felt  usually  just  about  the  internal  condyle.  In  such  cases,  if  occurring 
in  children  under  the  age  of  six  or  seven,  a  mere  loosening  without  displacement 
of  the  whole  lower  epiphysis  may  have  occurred,  or  more  probably  the  injury 
shown  in  Plate  VI.  without  the  displacement,  and  this  is  very  likely  the  most 
common  accident,  though  we  have  as  yet  no  sufficient  proof  that  it  is  so. 
Sometimes  the  whole  lower  epiphysis  is  separated  and  displaced  backwards 


Fig.  209. — Separation  of  epiphysis  of  humerus,  showing  adduction 
of  the  forearm  with  loss  of  the  '  carrying  angle.' 


Fig.  210. — Arrest  of  growth 
of  the  radius  from  separa- 
tion of  the  lower  epiphysis 
many  years  before. 


(Plate  VII.)  ;  more  often  the  capitellum  and  outer  condyle  are  detached 
(Plate  IX.)  and  the  inner  side  of  the  bone  fractured  (Plate  VI.).  Such  cases, 
if  seen  at  once,  should  be  treated,  after  reduction  of  any  obvious  deformity, 
by  gutta-percha  or  Gooch  splint,  on  one  side,  and  on  the  other  an  angular 
splint,  reaching  from  the  shoulder  to  the  end  of  the  fingers,  or  a  posterior 
angular  splint  may  be  used.  Treatment  of  these  injuries  of  the  lower  end 
of  the  humerus  by  keeping  the  arm  extended  has  been  recommended  as 
tending  to  diminish  the  displacement  due  to  contraction  of  the  triceps  and 
the  tendency  to  tilting  of  the  fragments,  but  this  method  of  treatment  has 
not   become    the   accepted    one.      H.    O.    Thomas,    R.    Jones,    and  others 


PLATE    VI. 


Beatrice  D.,  get.  2i  years.  Separation  of  tlie  whole  lower 
epiphysis  of  the  humerus,  with  inward  displacement, 
and  a  vertical  split  in  the  shaft.  The  diaphysis  projects 
outwards.     Loss  of 'carrying  angle.' 


Separation  of  the  lower  epiphysis  of  the  humerus, 
with   bactcward  displacement. 


PLATE    VIM. 


Separation  of  lower  epiphysis  of  humerus,  with  T  fracture.  Subluxation 
of  radius  forwards.  Injury  four  years  ago.  Good  mobility.  Boy 
set.  11  years. 


Separation  of  the  capitellar  epiphysis  In  a  girl  set.  7  years.  There 
was  mobility  through  about  70°,  and  good  power  of  pronation 
and  supination.     A  points  to  loose  fragment. 


PLATE   X. 


Separation  of  the  lower  epiphysis  of  the  radius  in  a  boy  set.  10  years. 


Separation  of  radial  epiphysis,  with  arrest  of  growth  two 
years  later.  Boy  aet.  12  years.  A  centre  of  ossification 
for  the  styloid  process  of  the  ulna  exists. 


Separation  of  the  Epiphyses  807 

recommend  treatment  by  supination  and  extension,  followed  by  acute  flexion 
of  the  elbow/  and  in  cases  where  a  radiogram  shows  a  backward  displace- 
ment which  cannot  be  otherwise  reduced  the  arm  should  certainly  be  put  up 
in  full  flexion.  At  the  end  of  a  week  the  splints  should  be  removed,  gentle 
active  movement  encouraged,  and  the  splints  re-adjusted.  A  week  later  all 
splints  should  be  left  off  and  the  arm  worn  in  a  sling,  but  taken  out  night 
and  morning  for  gentle  exercise.  Violent  passive  movement  to  keep  up 
flexibility  is  mischievous  and  delays  the  cure,  since  the  irritation  increases 
the  amount  of  callus  thrown  out.  If  no  passive  or  forcible  movement  is 
allowed,  but  just  gentle  voluntary  exercise,  absorption  of  all  thickening 
gradually  takes  place,  and,  provided  the  displacement  has  been  fairly 
corrected,  almost  perfect  mobility  will  return  in  the  course  of  a  few  months. 
The  great  point  in  treatment  is  to  reduce  the  deformity  and  avoid  forcible 
movement,  but  encourage  gejitle  active  movements  after  about  the  end  of 
the  first  week.  The  ultimate  prognosis  is  good  as  regards  mobility,  though 
uncertain  as  to  arrest  of  growth.     It  occasionally  happens  that  after  separa- 


Fig.  211. — Separation  of  the  lower  epiphysis  of  the  radius  (photograph  by  Franic  Ashe,  M.B.). 

tion  of  the  whole  lower  humeral  epiphysis  union  takes  place  with  the 
lower  segment  of  the  limb  adducted,  i.e.  there  is  loss  of  the  'carrying 
angle,'  and  an  unsightly  and  somewhat  awkward  limb  {vide  fig.  209  and 
Plate  VI.).  Loss  of  the  'carrying  angle'  or  cubitus  varus  may  arise  in 
injuries  of  the  elbow  from  displacement  of  one  or  other  side  of  the  lower  end 
of  the  humerus  or  from  abnormal  growth  after  injury.  It  is  very  unsightly, 
but  does  not  very  seriously  interfere  with  the  use  of  the  arm  in  most  cases. 
In  one  case  we  twice  osteotomised  the  humerus  to  remedy  the  deformity, 
which,  however,  recurred.  Even  if  the  limb  is  in  the  natural  position  after  the 
accident,  it  may  become  deformed  in  the  course  of  subsequent  growth  (Piatt). 
Separation  of  the  epicondylar  epiphysis  is  fairly  common  in  patients  from 
ten  to  sixteen  years  old,  and  the  displacement  is  usually  downwards. 

Separation  of  the  lower  epiphysis  of  the  radius  with  fracture  of  the  ulna 
is  said  to  differ  from  Colles's  fracture  in  that  the  palmar  projection  is  more 
obvious,  the  hand  is  not  held  so  obliquely,  i.e.  there  is  not  so  much  radial 

1   Brit.  Med.  Juur.  January  23,  1892,  and  November  3,  1894;  also  Helferich. 


8o8 


Injuries,  Shock,  Hcsmorrhage,  &c. 


adduction,  and  the  dorsal  groove  is  horizontal  instead  of  oblique.  There  is 
more  resemblance  to  dislocation  of  the  carpus  backwards  ;  but  this  is  an 
exceedingly  rare  injury,  and  in  it  the  styloid  processes  do  not  maintain  their 
normal  relations  to  the  carpus  as  they  do  in  fracture,  while  the  age  of  the 
patient  and  the  sensation  of  crepitus,  together  with  the  ease  of  reduction,  but 
ready  renewal  of  deformity,  will  point  to  diastasis  ^  (figs.  210  and  211,  and 
Plate  X).  If  the  ulna  is  not  fractured  the  resemblance  to  Colles's  fracture  is 
very  close,  and  the  treatment  is  the  same.  For  cases  illustrating  these  injuries 
in  the  upper  extremities  we  must  refer  to  Mr.  Tubby's  paper  arid  Mr.  Poland's 
work.  Arrest  of  growth  may  follow  (fig.  210,  and  Plate  XL).  Very  rarely 
the  upper  epiphysis  of  the  radius  is  detached.  We  have  once  met  with 
epiphysial  separation  at  the  symphysis  pubis  associated  with  rupture  of 
the  urethra. 

In  separation  of  the  lower  epiphysis  of  the  femur 
the  lower  fragment  is  usually  displaced  forwards, 
and  the  backward  pressure  of  the  diaphysis  upon 
the  vessels  may  cause  gangrene,  as  in  cases  of 
Wheelhouse's  and  McGill's  of  Leeds.-  We  have 
seen  cases  of  compound  separation  of  the  lower 
epiphysis  with  similar  displacement.  The  dis- 
placement should  be  rectified  under  chloroform, 
and  the  limb  put  upon  a  Macintyre's  splint  or  an 
inclined  plane.  Reduction  is  more  easily  effected 
by  flexion  of  the  limb  at  knee  and  hip  joints 
(Hutchinson).  If  necessary,  the  part  should  be 
exposed  by  operation  and  the  deformity  reduced. 
In  many  cases  the  onset  of  gangrene  appears  to 
have  necessitated  amputation.^  The  displacement 
is  occasionally  lateral. 

In  separation  of  the  upper  epiphysis  of  the 
tibia,  which  is  rare,  the  epiphysis  is  usually  dis- 
placed forwards,  though  it  may  be  laterally.  We 
have  seen  a  case  of  separation  of  the  lower  epi- 
physis of  the  tibia  in  a  boy  of  about  ten  years  who 
was  under  the  care  of  our  colleague  Mr.  Hardie. 
The  case  was  complicated  by  the  presence  of  a 
upwards  from  the  epiphysial  line.  The  foot  and 
lower  fragment  were  displaced  outwards,  and  the  deformity  could  not  be 
reduced  until  some  weeks  after  the  accident,  when  the  ends  of  the  bone 
were  exposed  by  operation  and  with  some  difficulty  replaced.  We  have 
also  met  with  an  instance  of  compound  separation  of  the  lower  epiphysis  of 
the  fibula.     The  lower  fragment  became  necrosed  and  was  removed. 

The  diagnosis  of  epiphysial  separations  need  not  be  further  described 
here  :  the  locality,  age  of  the  patient,  and  the  symptoms  mentioned  usually 
make  the  case  clear,  and  any  injury  in  the  neighbourhood  of  a  joint  ofdoubt- 

1  Vide  R.  W.  Smith  on  Fractures  and  Dislocations. 

2  Brit.  Med.  Jour.  May  24,  1884. 

^  Mayo  Robson,  Anttals  of  Surgery,   1893,  vol.  xviii.  ;   Tubby,  Antials  of  Surgery, 
1894,  vol.  xix. 


Fig.  212.  — Separation  of  lower 
epiphysis  of  left  femur.  The 
epiphysis  is  displaced  for- 
wards, and  the  knee  is 
flexed. 


vertical  fracture  running 


Separation  of  the  lower  epiphysis  of  the  femur,  with  vertical  fracture 
of  the  shaft.     From  a  young  man  get.  18  years. 


Separation  of  the  Epiphyses  8 09 

ful  character  should  l)c  treated  as  if  a  diastasis  liad  occurred.  After  a  few 
days  the  subsidence  of  the  general  swelling  and  the  presence  or  absence  of 
callus  will  clear  up  the  doubt,  even  if  a  careful  examination  under  chloro- 
form fails  to  reveal  the  exact  nature  of  the  injury. 

For  further  details,  with  records  of  cases,  we  must  refer  to  Mr.  Tubby's 
interesting  papers,  to  Mr.  J.  Hutchinson's,  jun.,  Lectures,  published  in 
the  '  British  Medical  Journal,'  1893-94,  and  above  all  to  Mr.  Poland's  book, 
which  gives  a  complete  account  of  the  whole  subject. 

The  treat)nent  of  these  cases  is  simply  that  of  a  fracture  in  the  same 
position,  though  lighter  appliances  may  of  course  be  used  in  the  case  of 
children  than  of  adults  ;  thus  poroplastic  felt,  Gooch's  splint,  Hide's  felt, 
gutta-percha  or  light  wooden  splints  may  be  employed.  Most  careful  padding 
is  necessary  in  all  cases  to  protect  the  tender  skin  ;  absorbent  wool  will  be 
found  the  best  material  for  this  purpose. 

In  separation  of  the  lower  epiphysis  of  the  femur,  as  already  stated,  the 
limb  should  be  put  up  in  the  flexed  position,  since  the  gastrocnemius, 
whether  attached  to  the  upper  or  lower  fragment,  tends  to  tilt  the  ends  of 
the  bone. 

Stimson  mentions  that  Volkmann  has  three  times  separated  the  lower 
epiphysis  of  the  femur  in  manipulations  recjuired  in  cases  of  hip  disease  ;  we 
once  met  with  the  same  mishap  in  a  case  of  acute  suppurative  arthritis  in  an 
infant.  The  ease  with  which  diastasis  occurred  was  probably  due  to  inflam- 
matory or  atrophic  softening  of  the  epiphysial  line.  The  child  recovered 
without  arrest  of  growth. 

In  all  cases  a  guarded  opinion  should  be  given  as  to  the  future  mobility 
of  the  adjacent  joint,  and  movement  should  be  begun  early — in  the  case  of 
the  elbow  not  later  than  the  end  of  the  first  week,  the  splints  being  re-applied 
afterwards,  and  movement  employed  dai4y  after  the  first  fortnight  ;  a  week 
longer  may  be  given  for  other  joints.  No  forcible  passive  movement  should 
be  employed  ;  if  the  fragments  have  been  replaced  it  is  unnecessary  and  even 
harmful  ;  if  they  are  still  out  of  position,  forcible  movement  is  useless  ;  and 
if,  after  time -has  been  given  for  absorption  and  modelling  down  of  the  parts, 
the  limb  is  still  seriously  crippled,  it  is  probably  better  either  to  resect  the 
joint  or  to  cut  down  upon  and  chisel  away  any  projecting  fragments  of  bone. 
Hence,  if  it  is  found  that  the  thickening  does  not  subside  it  is  well  to  cease 
movement  and  allow  the  parts  to  settle  down,  and  mobility  will  probably 
return  without  any  special  effort.  Separated  epiphyses  unite  with  great 
rapidity,  much  more  so  than  fractures.  Even  if  there  is  considerable  thick- 
ening and  distortion  for  some  weeks  after  the  injury,  and  perhaps  con- 
siderable loss  of  power  and  mobility,  so  much  modelling  of  the  parts  takes 
place  that  ultimately  the  result  is  usually  good. 

In  cases  of  compound  separation  of  an  epiphysis  it  may  be  necessary  to 
resect  part  of  the  shaft  of  the  long  bone  in  order  to  reduce  the  displacement. 
Even  in  such  cases  the  amount  of  ultimate  shortening  may  be  very  little, 
though  it  is  quite  uncertain  how  much  it  will  be. 

Implication  of  the  musculo-spiral  nerve  in  the  callus  of  a  separated  lower 
epiphysis  of  the  humerus  is  not  uncommon,  and  there  may  be  paralysis  of 
the  nerve  for  a  time  ;  usually,  however,  this  disappears,  and  no  hasty  opera- 
tion for  the  release  of  the  nerve  is  called  for. 


8io  Injuries,  Shock,  Hcemorrhage,  &c. 

The  following  table  of  the  dates  of  ossification  and  union  of  the  epiphyses 
of  the  principal  long  bones  is  inserted  from  Quain's  'Anatomy  : ' 

Humerus. 

Nucleus  of  head  appears  in  second  year. 

,,  capitellum  appears  in  third  year. 

„  internal  condyle  appears  in  fifth  year. 

„  trochlea  appears  in  the  eleventh  to  twelfth  year. 

„  external    condyle    appears  in  thirteenth   to   fourteenth 

year. 
The  lower  epiphyses  unite  with  shaft  in    sixteenth  to  eighteenth 

year. 
The  upper  epiphysis  unites  with  shaft  in  twentieth  year.^ 

Radius. 

Nucleus  of  lower  extremity  appears  at  end  of  second  year. 

„         head  appears  in  fifth  year. 
Upper  epiphysis  and  shaft  join  in  seventeenth  to  eighteenth  year. 
Lower  epiphysis  and  shaft  join  in  twentieth  year. 

Femur. 

Nucleus  of  lower  end  appears  at  ninth  month. 

„         head  appears  at  end  of  first  yeai". 
Head  joins  shaft  at  eighteenth  or  nineteenth  year. 
Lower  epiphysis  joins  shaft  after  twentieth  year. 

Tibia. 

Upper  epiphysis  appears  about  lime  of  bii'th. 

Lower  epiphysis  appears  in  second  year. 

Lower  epiphysis  joins  shaft  in  eighteenth  to  nineteenth  year. 

Upper  epiphysis  joins  shaft  in  twenty-first  or  twenty-second  year. 

Simple  complete  fractures  of  the  long  bones  may  be  met  with  at  any 
age,  and  even  occur  sometimes  in  utero  ;  indeed,  compound  fractures  may 
occur  before  birth.  Intra-uterine  fractures  may  be  the  result  of  falls  or  of 
blows  upon  the  mother's  abdomen,  or  of  muscular  contraction,  and  are  some- 
times associated  with  intra-uterine  rickets.  Almost  any  number  of  fractures 
may  thus  occur  ;  200  were  found  in  one  instance  and  113  in  anothei-.  Such 
fractures  may  be  found  united  at  birth  ;  they  are  not  very  rarely  produced 
during  labour  by  instruments  or  traction  upon  a  limb. 

Fractures  of  the  clavicle  in  quite  young  children  are  best  treated  by  a 
flannel  bandage  to  fix  the  arm  to  the  side  with  the  hand  on  the  opposite 
shoulder,  and  a  soft  pad  of  absorbent  wool  in  the  axilla.  The  child's  arm 
is,  of  course,  kept  inside  its  clothes,  and  not  put  through  a  sleeve  ;  as  Mr. 
Owen  suggests,  a  jersey  may  be  usefully  worn  over  the  bandage  to  keep  the 
limb  quiet.  In  this,  as  in  all  fractures,  it  is  an  excellent  plan  to  keep  the 
skin  well  powdered  with  boric  acid  or  sanitary  rose  powder,  so  as  to  prevent 
irritation  of  the  skin. 

'  Stimson  says  sometimes  as  late  as  the  twenty-fifth  year. 


PLATE    XIII. 


Fracture  above  epiphysial  line  of  lower  end  of  humerus. 
Loss  of  'Carrying  angle.'  Boy  set.  6  years.  Injury 
four  months  ago. 


PLATE    XIV. 


Fracture  of  neck  of  femur,  possibly  diastasis 
Boy  aet.  11   years 


Fractures  8 1 1 

Fractures  of  the  arm  are  treated  in  the  ordinary  way  ;  the  spHnts  should 
always  be  carried  well  up  to  the  ends  of  the  fingers  to  prevent  disturbance 
of  the  fragments  by  the  restless  movements  of  children.  We  are  well  aware 
that  this  is  not  usually  recommended,  but  we  believe  it  to  be  the  proper,  as 
it  certainly  is  the  anatomically  correct  plan.  Fractures  of  the  pelvis  are 
treated  by  bandaging'  the  legs  together  firmly  with  a  broad  flannel  bandage, 
which  is  carried  upwards  to  above  the  crests  of  the  ilia,  the  child  being,  of 
course,  kept  in  bed. 

In  fractures  of  the  femur  in  babies  under  a  year  old  a  piece  of  gutta- 
percha or  Gooch's  splint,  lined  with  wool,  should  be  applied  to  the  thigh, 
and  the  legs  bandaged  together  with  a  flannel  bandage  ;  this  is,  we  think, 
the  simplest,  cleanest,  and,  on  the  whole,  most  effectual  plan,  though  a  good 
result  may  be  obtained  by  almost  any  method.  In  older  children,  up  to  the 
third  or  fourth  year,  we  prefer  the  vertical  suspension  plan,  as  more  cleanly 
and  efficient,  and  less  troublesome  after  it  is  once  applied  than  other 
methods  ;  simple  extension  by  a  weight,  with  Gooch's  splint,  or  an  outside 
long  splint,  is,  however,  satisfactory,  and  a  Croft's,  a  Bavarian,  or  a 
Thomas's  hip  splint  should  be  applied  at  the  end  of  a  fortnight.  Thomas's 
knee  splint  may  also  be  used  very  successfully  in  fractures  of  the  lower  half 
of  the  femur. 

After  fracture  of  the  thigh  in  simple  cases  there  should  not  be  at  most 
more  than  half  an  inch  shortening  in  young  children,  and  this  will  very 
likely  disappear  after  a  time. 

Fracture  of  the  neck  of  the  femur  occasionally  occurs  in  children. 

Case. — W.  L.  S. ,  set.  14.  Fell  from  a  door  in  May  1896.  He  was  laid  up  for  a  fort- 
night. When  seen,  six  .months  later,  there  was  one  inch  shortening  of  the  right  leg,  no 
abduction  or  adduction.  The  trochanter  was  raised  to  the  level  of  the  anterior  superior 
spine.  There  was  some  stiffness,  and  no  pain.  The  radiogram  Plate  XIV.  was  taken  six 
months  after  the  accident,  when  he  was  an  out-patient  at  the  Children's  Hospital. 

Fractures  of  the  leg  should  be  treated  by  a  back  splint  with  a  foot-piece 
and  two  side  splints  for  the  first  ten  days  or  a  fortnight,  or  more,  according 
to  age,  and  tlien  one  of  the  forms  of  stiff  apparatus  applied. 

In  all  cases  the  most  careful  watch  must  be  kept  for  tight  bandages  ;  no 
bandage  should  ever  be  appHed  beneath  a  splint,  nor  should  a  hmb  be  ever 
bandaged  in  extension  and  then  put  up  in  flexion.  Pressure  sores  and 
gangrene  are  real  dangers  in  children. 

As  is  well  known,  any  cause,  such  as  hip  disease,  infantile  paralysis,  old 
anchylosis  with  atrophied  bone,  rickets,  and  so  on,  may  produce  weakening 
of  the  limb  and  may  predispose  to  fractures  from  slight  violence.  When 
e.xtensive  necrosis  has  occurred,  a  slight  injury  may  produce  a  fracture  in 
childhood  ;  this  usually  unites  well,  but  in  some  cases  union  is  tedious,  and 
in  others  does  not  occur  :  in  such  cases  resection  and  wiring  is  a  successful 
operation  in  our  experience,  but  if  the  fracture  remains  long  ununited  the 
wasting  of  the  fragments  is  apt  to  be  extreme,  and  in  one  instance  the  upper 
fragment  of  the  humerus  was  so  small  that  it  was  found  impossible  to  steady 
it  sufficiently  to  obtain  union.  Macewen  has  dealt  with  such  a  case  most 
successfully  by  transplantation  of  bone  (i.dde '  Ununited  Fractures  ').  This 
bony  atrophy  should  always  be  borne  in  mind  when  dealing  with  such  limbs. 

Mal-united   fractures,  if  recent,  and  especially  if  greenstick,  should  be 


8i2  Injuries,  Shock,  Hcemorrhage,  &c. 

refractured  at  once  ;  if  seen  after  three  or  four  weeks,  and  when  union  has 
occurred,  gradual  reduction  with  spHnts  often  produces  good  results.  Failing 
this,  refracture  or  osteotomy  may  be  called  for. 

Primary  iLmputations  in  children  are  very  rarely  required,  and  conser- 
vatism should  be  carried  to  extreme  limits  ;  when  amputation  is  necessary, 
if  the  immediate  shock  is  got  over,  recovery  is  usually  rapid.  We  have  had 
once  to  perform  a  primary  amputation  at  the  hip  in  a  child  five  years  old  for 
a  tramcar  injury,  and,  though  there  was  much  '  prostration  with  excitement ' 
for  the  first  two  days,  he  ultimately  did  well. 

Primary  Resections  of  joints  are  occasionally  required,  and  in  cases  of 
injury  to  the  elbow  are  spoken  very  highly  of  by  Mr.  Holmes.  The  need  for 
them  is,  however,  now  exceedingly  rare. 

Dislocations. — Almost  the  only  dislocation  at  all  common  in  children  is 
that  of  the  elbow — both  bones  being  displaced  backwards.  This  is  usually 
said,  and  we  believe  correctly,  to  be  more  frequently  met  with  in  childhood 
than  in  adult  life.  Dislocation  of  the  elbow  is,  however,  often  complicated 
with  separation  of  epiphyses  or  fractures,  and  the  displacement  is  often  not 
directly  backwards,  but  backwards  and  laterally,  either  inwards  or  outwards. 
Passive  movement  should  be  begun  at  the  end  of  a  week  at  latest. 

Dr.  W.  T.  Clegg;  of  Liverpool,  has  sent  us  a  case  of  subspinous  dis- 
location of  the  shoulder,  probably  caused  at  birth  ;  this  is  the  only  case  we 
have  seen. 

Subluxation  of  the  head  of  the  radius  is  often  met  with  in  children  as  a 
result  of  lifting  the  child  b)'  one  arm,  swinging  it  round,  or  dragging  it  along. 
The  head  of  the  radius  slips  partially  out  of  the  orbicular  ligament,  and  the 
arm  is  found  to  be  fixed,  powerless,  somewhat  flexed  and  pronated  ;  there  is 
usually  pain  both  at  the  elbow  and  wrist,  so  that  sometimes  the  injury  has 
been  thought  to  be  situated  at  the  wrist  joint.  Reduction  is  effected  by 
steadying  the  upper  arm,  and,  with  the  thumb  over  the  head  of  the  radius, 
supinating  sharply,  and  then  flexing  the  forearm  upon  the  arm  ;  sometimes 
a  distinct  click  is  felt  or  heard,  and  the  power  of  using  the  arm  at  once 
returns.^ 

We  have  only  rarely  met  with  a  traumatic  dislocation  (dorsal)  of  the  hip 
in  children.  Reduction  is  easy  by  manipulation.  Dislocation  of  the  patella 
is  occasionally  met  with  ;  there  appears  to  be  usually  some  congenital  weak- 
ness of  the  part  as  a  predisposing  cause,  as  in  the  case  appended. 

Case. — Dislocation  of  Patella. — Mary  Alice  N.,  aged  7  years  6  months;  admitted 
February  7,  1883.  History  :  Not  strong,  did  not  walk  till  three  years  old  ;  seven  months 
ago  fell  while  dancing  and  dislocated  the  left  patella  outwards  ;  since  then  has  been  con- 
stantly falling  on  account  of  the  displacement  recurring,  especially  if  she  runs  ;  the  injury 
caused  her  no  great  trouble  for  a  week,  when  the  displacement  was  noticed  ;  was  treated 
as  an  out-patient  for  some  time,  with  pads  and  various  appliances  to  keep  the  patella  in 
place,  but  without  success.  On  admission,  the  left  patella  during  flexion  lies  quite  on  the 
outer  side  of  the  external  condyle,  coming  back  to  its  normal  position  on  extension  ;  both 
femora  have  their  external  condyles  very  prominent ;  no  pain  on  manipulation  or  move- 
ment ;  the  patella  was  unnaturally  small  and  could  easily  be  moved  about  from  side  to 
side  ;  when  walking  it  sometimes  maintained  its  proper  position,  and  then  without  warn- 


1  This  injury  has  been  specially  described  by  Mr.  Jonathan  Hutchinson,  jun. ,  and  by 
Drs.  McNab  and  Linderaan,  Brit.  Med.  Jour.  December  5,  1885. 


Dislocations 


813 


ing  would  slip  (|uite  over  the  outer  eondyle  and  make  the  leg  yield.  February  17,  a 
lateral  ineision  was  made  over  the  inner  side  of  the  joint  down  to  the  capsule,  the  patella 
pushed  strongly  inwards,  and  two  catgut  sutures,  passed  through  the  inner  edge  of  the 
patella,  were  tied  firmly  down  to  the  tissues  on  the  inner  side  of  the  joint ;  operation 
antiseptic  ;  hack  splint.  19th,  has  had  a  little  pain  ;  did  quite  well  ;  antiseptics  left  off 
on  March  3,  and  she  was  sent  out  in  plaster  of  Paris  splint  on  the  5th.  Seen  January 
1884,  the  patella  keeps  its  place  and  the  knee  does  not  trouble  her.  In  this  case  the 
patella  was  apparently  congenitally  small  and  ill  developed,  and  this  probably  accounts 
for  the  condition. 

Subluxation  of  the  knee  has  been  recently  described  by  Mr.  H.  B. 
Robinson  as  occurring  in  children  about  twelve  months  old,  and  apparently 
the  result  of  relaxed  muscles  and  ligaments.     The  tibia  becomes  displaced 


outwards,  and  rotated  out  on  attempts  being  made  to  walk.  Attention  to 
the  general  health  and  friction  are  the  only  modes  of  treatment  required, 
and  the  tendency  to  displacement  disappears  as  the  child  grows  stronger.^ 

Cong-enital  Dislocations  are  considered  under  the  head  of  Malforma- 
tions (p.  750). 

Injuries  of  the  Soft  Parts  in  children  require  no  special  notice  ;  if  the 
immediate  shock  is  got  over,  such  wounds  usually  heal  with  great  rapidity 
even  if  very  severe,  and  nothing  short  of  actual  gangrene  (Holmes)  should 
be  considered  justification  for  amputation.  Warmth,  opium  in  small  doses, 
and  free  stimulation  are  especially  required  for  all  severe  injuries  in  children. 

Burns  and  Scalds  are  exceedingly  fatal,  chiefly  from  shock,  lung  com- 
plications, and  cerebral  effusion.  If  the  first  few  days  can  be  tided  over, 
recovery  is  usually  satisfactory,  and  much  more  rapid  than  in  adults.     Care- 

•■  B7-it.  Med.  Jour.  July  27,  1895. 


8 14  Injuries,  Shock,  Hcemorrhage,  ffc. 

ful  watch  for  cicatricial  contraction  must  be  kept  up,  and  provision  made 
against  it  by  suitable  extension  apparatus  and  manipulation,  as  well  as  by 
grafting".     Plastic  operations  may  be  required  at  a  later  date. 

Shock. — The  question  of  how  children  bear  the  shock  of  severe  injuries 
or  operations,  and  the  effects  of  loss  of  blood  and  of  pain,  is  one  of  much 
importance  to  the  surgeon,  and  may  be  shortly  considered  here.  First,  then, 
as  regard  operations  in  infants  and  quite  young  children  one  great  depressing 
element  is  removed.  They  do  not  anticipate  and  are  not  cast  down  by  the 
thought  of  the  effect  upon  their  future  usefulness  of  any  mutilation.  In  some- 
what older  children  anticipation  of  pain  is  of  course  keen,  but  it  seldom  de- 
presses in  the  same  way  that  it  does  in  adults.  Again,  the  temperament  of 
children  is  usually  mobile,  and,  even  if  mental  depression  occurs,  it  is  not 
long  lasting.  So  with  shock  from  a  severe  injury  or  operation,  the  symptoms 
are  often  severe,  even  more  so  than  in  adults,  for  a  short  time  ;  but,  if  by 
means  of  stimulants  the  first  few  hours  can  be  got  over,  children  very 
quickly  rally.  It  is  common  to  have  a  great  amount  of  shock  in  a  child 
after  such  an  operation  as  an  amputation  or  excision  of  one  of  the  larger 
joints,  and  yet  the  next  day  the  child  is  often  as  bright  as  if  nothing  had 
happened.  On  the  other  hand,  occasionally  we  see  '  prostration  with  excite- 
ment '  in  a  severe  form  in  children,  and  we  have  known  a  mental  condition 
practically  identical  with  acute  mania  coming  on  after  amputation  at  the 
shoulder  joint,  and  lasting"  for  some  weeks,  followed  by  complete  recovery. 

Iioss  of  blood  is  always  very  ill  borne  by  children,  and  the  more  so  the 
younger  the  child.  Still,  recovery  is  rapid  if  the  child  survives.  Even  the 
small  quantity  lost  in  a  harelip  operation  sometimes  seriously  endangers 
the  life  of  an  infant  a  few  weeks  old,  and  in  all  cases  great  care  should  be 
taken  to  avoid  haemorrhage  as  much  as  possible.  The  only  instance  of 
death  from  amputation  at  the  hip  joint  that  we  have  had  in  a  child  was  in 
one  where,  from  removal  of  a  large  part  of  the  pelvis,  free  oozing  took  place. 

Next  to  loss  of  blood  we  should  put  cold  as  having  the  most  depressing 
effect  upon  children,  and  this  should  always  be  carefully  guarded  against  by 
exposing  as  little  as  possible  of  the  body  beyond  that  part  actually  being 
operated  upon. 

Fain,  if  really  severe,  very  seriously  depresses  a  child,  far  more  so 
than  it  does  an  adult,  and  many  of  the  cases  of  severe  burn  die  speedily 
from  the  combined  effects  of  pain  and  fright.  Hence,  no  child  should  be 
allowed  to  lie  in  pain  after  an  operation,  and  opium  should  be  given  freely 
for  a  few  hours  till  the  first  soreness  has  passed  off,  bearing  in  mind, 
of  course,  that  opium  has  a  disproportionately  strong  effect  upon  children, 
and  that  some  children  bear  much  smaller  doses  than  others.  The  general 
rules,  then,  to  be  followed  as  to  the  management  of  surgical  cases  in 
childhood  are:  (i)  Do  not  let  a  child  know  that  he  is  going  to  be 
operated  upon,  until  the  time  actually  comes  for  the  operation.  (2)  Avoid 
with  the  utmost  care  unnecessary  loss  of  blood.  (3)  Keep  the  child  warmly 
wrapped  up.  (4)  Never  let  a  child  suffer  pain  if  it  can  be  avoided  ;  thus,  an 
anaesthetic  should  be  given  for  any  painful  dressing  or  manipulation,  and 
opium  as  soon  as  recovery  from  the  anaesthetic  has  taken  place. 

As  Mr.  Holmes  has  well  pointed  out,  in  children  '  irritability  is  chiefly 
directed    against    sudden    and  acute   pain  ;  but   confinement    to   bed  and 


Septic  Diseases  815 

protracted  disease,  which  wear  out  the  patience  and  exhaust  the  hopes  of 
older  persons,  soon  become  customary  in  childhood,  and  then  produce  little 
impression.'  As  Mr.  Holmes  shows,  freedom  from  mental  depression  and 
healthy,  unimpaired  excretory  organs  probably  account  for  this  difference. 

Children  are,  of  course,  liable  to  the  same  septic  diseases  as  adults,  and 
pyemia  is,  though  happily  rare  in  both,  quite  as  common  in  childhood  as  in 
older  patients.  Diphtheria,  and  especially  scarlet  fever  [iiide  Chap.  XIV.), 
are  ver>'  apt  to  attack  surgical  cases  among  children,  i.e.  those  in  whom  there 
is  a  wound  or  a  local  inflammatory  focus  ;  while  erysipelas,  though  not  very 
rare  and  occasionally  fatal,  is  mostly  of  a  mild  type  in  children,  and  in  our 
experience  the  so-called  '  erysipelas  vagans '  is  the  variety  most  commonly 
met  with.     See,  however.  Vaccination  Erysipelas,  p.  310. 

'  Surgical  scarlet  fever,'  so-called,  is  nothing  more  than  ordinary  scarlet 
fever.  It  is  now  well  known  that  children  who  have  open  wounds,  who  have 
been  recently  operated  upon,  or  who  have  local  inflammatory  foci,  such  as 
abscesses,  are  specially  susceptible  to  scarlet  fever.  For  further  details  and 
references  we  must  refer  to  papers  by  Dr.  Goodhart  and  Messrs.  Howse 
and  Paley,  in  the  '  Guy's  Hosp.  Repts.'  for  1879,  and  to  an  account  of  an  out- 
break in  our  own  surgical  ward,  by  R.  W.  Murray,  in  the  '  Brit.  Med.  Jour.' 
June  18,  1887. 

No  special  remarks  are  required  upon  the  subject  of  dressing  wounds  in 
children  ;  the  same  rules  should  be  followed  as  in  adults.  We  use  anti- 
septics— chiefly  boric  and  mercurial  lotions,  with  iodoform  and  sublimate 
wood-wool  wadding — and  are  fully  satisfied  of  the  value  of  these  agents. 
IMercurial  poisoning  in  children  we  have  not  certainly  met  with,  and  only 
iodoform  poisoning  in  a  few  instances,  and  those  of  a  very  mild  type.  We 
have  twice  had  a  fatal  result  follow  within  twenty-four  hours  of  emptying 
and  washing"  out  a  large  abscess,  but  we  have  been  unable  to  connect  the 
death  definitely  with  the  use  of  any  particular  antiseptic  agent,  though  we 
have  suspected  perchloride  of  mercury  of  being  dangerous  in  such  cases. 

In  certain  cases — for  instance,  in  circumcision — it  is  well  to  avoid  the 
fright  of  a  second  manipulation  by  the  use  of  catgut  sutures  in  closing  the 
wound,  and  it  may  be  remarked  that  primary  imion  of  wounds  in  children  is 
much  more  easily  obtained  than  in  adults,  providing  the  child  is  healthy  and 
not  too  young  ;  in  the  very  young  the  tissues  are  too  soft  to  bear  any  strain, 
and  in  childhood  the  very  smallest  disturbance  of  health  is  sometimes 
enough  to  prevent  union  of  a  wound  ;  hence  all  plastic  operations  should  be 
performed  only  after  careful  inquiry  into  the  child's  general  condition.  The 
same  slight  causes  will  often  produce  a  temperature  chart  that  would  be  very 
alarming  if  it  were  not  known  how  little  is  required  to  raise  a  child's  tempe- 
rature. As  to  the  dieting  of  children  after  operations,  it  will  be  found  that 
children  can  without  harm  much  more  speedily  return  to  their  ordinary 
diet  than  can  adults,  and  it  is  common  for  a  child  to  resume  its  usual  food 
the  day  after  an  operation. 

We  have  two  or  three  times  met  with  cases  of  persistent  vomiting  after 
operation  resisting  all  treatment  and  even  proving  fatal  by  exhaustion.  In 
one  instance,  after  operation  for  cleft  palate,  the  vomiting  was  followed  by 
purpura,  gangrene  of  the  extremities,  endocarditis,  and  death  from  acute 
septicaemia. 


8i6  AncBsthetics  for  Children 


CHAPTER   XL 

ANESTHETICS    FOR   CHILDREN 

By  Alexander  Wilson,  F.R.C.S. 

In  the  production  of  anaesthesia  in  children,  as  compared  with  adults, 
there  are  two  questions  to  be  chiefly  considered  ;  their  physical  conformation 
— that  is,  their  capacity  for  the  inhalation  and  absorption  of  the  aneesthetic 
vapour — and  its  reaction  on  their  more  unstable  nervous  and  usually  healthy 
vascular  systems. 

General  anaesthesia  takes  place  when  the  blood  of  the  subject  contains  a 
certain  definite  quantity  of  the  aneesthetic  agent  employed,  which  is  intro- 
duced through  the  lungs,  by  the  inhalation  of  air  impregnated  with  the 
ancesthetic.  It  follows  that  the  strength  of  the  ansesthetic  vapour  being  the 
same,  the  rapidity  with  which  the  blood  absorbs  and  distributes  the 
necessary  amount  of  the  drug  will  depend  upon  the  depth  and  fi'equency 
of  the  respirations,  i.e.  upon  the  vital  capacity,  and  also  upon  the  vigour  of 
the  circulation  in  proportion  to  the  size  of  the  animal,  small  animals, 
which  breathe  deeply  or  quickly  in  proportion  to  their  size,  becoming  affected 
sooner  than  larger  animals,  which  breathe  slowly.^ 

Compared  with  adults,  children  present  well-marked  differences.  Their 
chests  are  usually  well  developed,  highly  expansile,  and  the  lungs  more 
likely  to  be  healthy  and  in  better  working  order.  They  consequently  have, 
in  proportion  to  their  size,  a  larger  vital  capacity  than  most  adults,  that 
is,  a  proportionately  larger  lung  area  for  the  inhalation  and  absorption 
of  any  anaesthetic  vapour.  Their  healthy  vascular  system  and  active 
circulation  enable  the  blood  to  quickly  absorb  and  transfer  the  inhaled  drug  to 
the  tissues,  and  their  smaller  size  causes  the  system  to  become  more  quickly 
affected.  In  pi'actice  the  influence  of  these  factors  is  often  increased  by  the  way 
in  which  young  subjects  usually  take  aneesthetics,  e.g.  crying,  and  alternately 
holding  the  breath  and  taking  deep  inspirations.  The  foregoing  considera- 
tions account  for  the  rapidity  with  which  children  go  '  under '  with 
anaesthetics,  and  one  has  seen  a  crying  struggling  child  reduced  to  an  almost 
lifeless  condition  by  one  deep  inspiration  of  a  concentrated  vapour  of 
chloroform.  Owing  to  this  capacity  for  the  inhalation  and  absorption 
of  anaethetics  and  the  small  size,  less  anaesthetic  is  required  ;  so  in  giving 
them  anaesthetics  caution  is  necessary,  and  an  over-dose  may  easily  be 
inhaled. 

1  Snow,  On  Aiicesthetics,  p.  70. 


Difference  hetzi-'cen   Childreti  and  Adnlts  S17 

As  regards  the  effect  of  the  anaesthetic,  children  possess  no  special 
resisting  power  against  the  lethal  action  of  either  chloroform,  ether,  or 
any  other  aniesthctic.  In  proportion  to  the  number  of  administrations, 
probably  fully  as  many  accidents  have  happened  in  the  case  of  children 
as  in  adults.  .  They  are  better  subjects  than  adults  merely  in  so  far  as 
they  are  more  free  from  those  degenerative  changes  which  in  older  subjects 
complicate  the  administration.  They  also  have  an  advantage  in  not 
being  habituated  to  the  excessive  use  of  alcohol,  &c.  Further,  as,  from 
the  elasticity  of  their  chest  wall  and  their  smaller  size,  treatment  in 
accidents  can  be  better  and  more  successfully  applied,  there  are  in  con- 
sequence fewer  fatal  cases. 

Apart  from  the  rapidity  with  which  the  anaesthetic  can  take  effect,  such 
differences  in  its  action  as  exist  are  to  be  traced  largely  to  the  activity  of  the 
reflexes  and  the  lack  of  inhibition  over  certain  functions  which  obtains  in 
young  subjects.  Thus  the  occurrence  of  defecation  and  micturition  is  more 
common  in  children,  probably  because  these  acts  are  with  them  normally 
under  less  control.  The  crying  reflex  is  abnormally  active  in  early  life,  and 
so  during  an  operation  a  child  will  often  cry  out  at  a  stage  of  the  narcosis 
where  an  adult  would  either  exhibit  no  sign  of  feeling  or  merely  move 
slightly.  Perception  of  pain  does  not  necessarily  accompany  the  crying.  It 
is  a  common  occurrence  for  a  child  to  emerge  shrieking  from  nitrous  oxide 
anaesthesia,  and  yet  for  it  to  have  no  painful  impression  nor  any  idea  why 
it  is  crying.  This  readiness  with  which  children  cry  out  is  partly  responsible 
for  the  belief  that  they  '  come  out '  of  chloroform  anaesthesia  more  quickly 
than  adults. 

In  adults  we  see  spasm  of  the  glottis  producing  loud  crowing  inspiration 
as  a  reflex  from  forcible  dilatation  of  the  sphincter  ani.  In  children  this  is  more 
readily  originated,  even  when  the  patient  is  apparently  well  '  under,'  and 
accompanies  any  painful  operative  procedure.  It  is  especially  well  marked 
on  division  of  the  prepuce  or  in  operations  involving  the  anus  during 
moderately  deep  narcosis.  It  represents  an  abortive  expulsive  effort,  and 
denotes  an  iraperfect  degree  of  anaesthesia,  and  is  relieved  but  not  removed 
by  extending  the  head  and  pushing  forwards  the  javv,  and  giving  more  of  the 
anaesthetic.  If  the  painful  part  of  the  operation  is  of  momentary  duration,  it 
is  not  necessary  or  advisable  to  push  the  anaesthetic  to  the  extent  of 
abolishing  this  reflex. 

Other  points  of  difference  between  childi-en  and  aciults  dependent  upon 
the  nervous  system  are  the  various  reflexes  by  which  the  degi^ee  of  narcosis 
is  estimated.  The  corneal  or  lid  reflex,  uncertain  as  it  is  in  adults  as  a 
guide  to  the  condition  of  ansesthesia,  is  still  more  unreliable  in  young- 
subjects.  In  applying  this  test  do  not  hold  up  the  lid  in  such  a  way  as  to 
prevent  it  closing,  and  always  test  both  eyes.  The  reflex  may  be  present 
throughout  an  operation  though  no  other  signs  of  sensation  are  exhibited, 
it  may  be  present  in  one  eye  and  absent  in  the  other,  and  it  may  be  absent 
in  both  eyes  and  yet  the  patient  exhibit  signs  of  sensibihty.  In  the  latter 
condition  the  pupils  are  contracted  and  the  eyes  have  a  fixed  look,  and  there 
are  generally  other  indications  of  decrease  in  the  aneesthesia.  It  has  been 
suggested  that  this  absence  of  corneal  reflex  may  be  due  to  the  local 
anaesthetic  effect  of  the  chloroform  vapour.     The  inferences  deduced  from 

^1  G 


8i8  AncEsthetics  for  Children 

the  lid  reflex  must  be  checked  by  observation  of  other  conditions,  such  as 
the  quantity  of  anaesthetic  the  patient  has  taken,  the  respirations,  facial 
expression,  the  swallowing  reflex,  movements  of  the  fingers,  and  nature  of  the 
operation. 

Emergence  from  the  narcosis  is  indicated  by  alteration  in  rhythm  of  the 
respirations,  shght  holding  of  the  breath  with  tendency  to  spasm  of  the 
glottis,  or  acceleration  of  the  respirations. 

Alteration  in  the  facial  expression,  pursing  of  the  lips,  or  wrinkling  of  the 
forehead,  and  extensive  movements  of  the  fingers  are  signs  of  recovery. 
Swallowing  is  a  late  reflex  to  disappear  and  an  early  one  to  re-appear,  and 
is  a  valuable  index  to  the  stage  of  anaesthesia. 

Symptoms  of  vomiting  also  denote  a  return  to  consciousness.  An 
intelHgent  observation  of  all  these  points  will  usually  enable  the  adminis- 
trator to  avoid  making  mistakes. 

The  state  of  the  pupils  alone  is  not  much  guide  to  the  degree  of  narcosis. 
They  are  dilated  at  an  early  stage,  generally  moderately  contracted  later, 
■dilate  on  the  onset  of  nausea  and  vomiting,  and  dilate  widely  in  collapse. 
The  significance  of  these  signs,  like  others,  must  be  interpreted  in  conjunc- 
tion with  other  symptoms. 

Children  are  very  susceptible  to  shock,  and  no  suddenly  painful  pro- 
cedure (e.g.  wrenching  a  joint)  should  be  undertaken  when  they  are  in  a 
semi-ansesthetised  state.  Though  the  occurrence  of  reflex  paralysis  of  the 
heart  has  been  denied  by  certain  recent  observers  (Hyderabad  Chloroform 
Commission),  we  have  seen  one  case  (a  young  girl)  in  which  death  was 
clearly  due  to  shock  produced  by  flexing  a  limb  when  the  patient  was  not 
completely  under  the  influence  of  the  anesthetic. 

The  Choice  of  an  ilnsesthetic. — In  this  connection  it  is  not  necessary 
to  consider  any  anaesthetic  agents  other  than  ether,  chloi'oform,  and  nitrous 
oxide,  or  their  various  combinations.  As  regards  relative  safety,  children 
are  in  the  same  position  towards  these  drugs  as  are  adults.  In  lethal  power 
chloroform  comes  first,  ether  next,  and  nitrous  oxide  last ;  the  latter,  it  must 
be  remembered,  has  not  been  used  to  any  extent  for  the  production  of 
prolonged  anaesthesia.  The  attempts  at  present  being  made  to  employ 
it  for  long  operations  may  possibly  prove  that  there  is  a  limit  to  its  safe 
use.  In  selecting  an  angesthetic  for  a  young  subject,  too  much  stress  must 
not  be  laid  upon  the  mere  question  of  age  ;  extreme  youth  does  not  neces- 
sarily contra-indicate  the  exhibition  of  ether,  nor  make  imperative  the  use  of 
chloroform  ;  if  necessary,  ether  can  as  readily  be  given  to  an  infant  as  to 
an  adult. 

Iiocal  Anaesthesia  for  exploratory  punctures  may  be  produced  by 
holding  a  piece  of  ice  dipped  in  salt  against  the  surface  until  it  is  frozen,  by 
ether  spray,  or  by  ethyl  chloride.  Cocaine,  from  the  method  of  applying 
it,  from  its  irregular  action,  and  the  unpleasant  symptoms  it  sometimes 
causes,  cannot  be  much  used  for  children. 

iritrous  Oxide  is  well  borne  by  children,  they  pass  rapidly  under  its 
influence,  but  the  period  of  anaesthesia  is  short,  and  muscular  movements, 
spasm,  and  opisthotonos  are  usually  much  greater  than  in  adults.  It  may 
always  be  used  in  dental  and  short  surgical  operations.  The  period  of 
anaesthesia  can  be  prolonged  and  the  muscular  disturbance  diminished  by 


Chloroform.     Etiicr  S19 

combinin.L;-  it  with  oxygen  or  a  little  ether.  This  latter  is,  however,  liable  to 
cause  sickness,  which  may  also  occur  after  prolonged  anaesthesia  from  the 
gas  alone. 

Chloroform  in  the  case  of  children  possesses  many  advantages,  but  it  is 
not  altogether  the  safe  and  desirable  anaesthetic  it  is  often  represented  to 
be.  Children,  as  already  stated,  possess  no  special  powers  of  resistance 
against  the  lethal  action  of  chloroform,  and  a  fair  number  of  deaths,  and 
many  more  alarming  but  non-fatal  accidents,  have  occurred  from  its  use  in 
young  subjects. 

The  youth  of  the  patient  is  a  soui'ce  of  safety  only  because  it  implies  a 
freedom  from  degenerative  changes  in  the  nervous,  respiratory,  and  vascu- 
lar systems. 

The  advantages  of  chloroform  consist  in  the  simplicity  of  the  apparatus 
required,  the  small  quantity  needed,  its  sweet  pleasant  flavour,  and  the  fact 
that  it  produces  no  bronchial  irritation.  As  disadvantages  may  be  mentioned 
the  facility  with  which  an  overdose  may  be  inhaled  ;  the  depression  it  pro- 
duces, indicated  by  pallor,  feeble  pulse,  dilated  pupils.  The  nausea  and 
faintness  after  the  administration  are  often  considerable,  and  have  led  some 
surgeons  to  prefer  ether  as  the  routine  antesthetic  for  children.  With 
chloroform  there  is  often  difficulty  in  producing  narcosis,  and  in  estimating 
and  graduating  the  degree  of  anaesthesia.  If  during  the  operation  there  is  a 
return  of  sensation,  it  is  not  so  easy  to  re-induce  anesthesia  with  speed  and 
safety.  This  arises  from  the  circumstance  that  when  once  a  certain  degree 
of  unconsciousness  is  produced  the  breathing  becomes  so  shallow  that 
barely  enough  chloroform  is  inhaled  to  advance  the  narcosis,  or  if  the 
patient  is  '  under '  to  keep  it  up. 

Ether,  compared  with  chloroform,  is  less  depressing  ;  the  pulse  continues 
strong  throughout,  the  respirations  active  ;  the  face  keeps  a  good  colour  ; 
the  tendency  to  syncope  is  diminished,  and  the  after-sickness  is  of  shorter 
duration,  often  ceasing  when  once  the  stomach  is  emptied  of  mucus.  It  is 
quicker  in  its  action  consistent  with  safety,  so  that  the  distressing  struggles 
of  a  child  can  be  speedily  ended  without  danger  in  a  way  that  could  not  be 
done  with  chloroform.  It  is  much  easier  to  calculate  and  maintain  a  definite 
degree  of  narcosis,  and  if  signs  of  returning  sensation  or  of  vomiting  appear 
a  deeper  anaesthesia  can  be  speedily  and  safely  re-induced,  probably  because 
the  drug  causes  active  respirations  and  is  therefore  more  freely  inhaled. 
The  risk  of  suddenly  giving  an  over-dose  is  almost  nil.  Ether,  however,  has 
disadvantages  ;  it  requires  some  apparatus  for  its  proper  administration,  it 
occasionally  causes  a  considerable  secretion  of  mucus,  and  when  given 
alone  it  is  unpleasant.  The  last  of  these  objections  can  be  overcome  by 
giving  it  in  combination  with  nitrous  oxide,  or  by  first  giving  a  little  chloro- 
form. The  secretion  of  mucus  in  children  is  no  greater  than  it  is  in  adults, 
and  when  the  inhalation  is  properly  managed  only  in  the  minority  of  cases 
is  it  enough  to  give  any  trouble.  When  excessive  it  may  readily  block  up 
the  small  trachea  and  bronchial  tubes,  and  give  rise  to  inconvenience, 
especially  if  the  patient  is  kept  deeply  narcotised.  In  these  cases  changing 
the  anaesthetic  to  chloroform  does  not  immediately  improve  matters,  as  the 
change  does  not  remove  the  mucus  ;  it  is  better  to  allow  the  patient  to 
recover  consciousness  enough  to   clear  the  lungs   by  coughing.     Ether  is 

3  G2 


820  AncBsthetics  for  Children 

contra-indicated  in  lung  disease,  and  is  supposed  to  be  dangerous  in  kidney 
diseases. 

The  A.C.i:.  ESixture  is  a  weaker  ansesthetic  and  not  as  depressing  as 
chloroform,  and  so  safer  ;  but  it  is  not  as  safe  as  ether. 

These  anaesthetics  are  also  used  in  combination,  the  object  being  to 
blunt  the  sensibility  to  the  pungency  of  ether  vapour.  The  principle  of  all 
these  combinations  is  first  to  give  the  more  agreeable  anaesthetic  until 
sensation  is  dulled  and  then  replace  it  with  pure  ether  before  the  stage  of 
excitement.  The  most  useful  is  nitrous  oxide  and  ether  ;  but  as  it  entails 
the  einployment  of  apparatus,  its  use  is  confined  to  older  children.  The 
initial  exhibition  of  chloroform  or  A.C.E.  followed  by  ether  is  very  valuable. 
Certain  anaesthetists  have  reduced  the  arrangement  to  a  definite  system.  As 
an  example  of  these  methods,  Mr.  Rowell  recommends  that  A.C.E.  should 
be  first  given  in  drop  doses  on  a  piece  of  lint  or  Skinner's  inhaler,  to  be 
followed  by  a  stronger  vapour  of  A.C.E.  from  a  Rendel's  mask,  to  which 
when  unconsciousness  supervenes  should  be  added  a  drachm  of  ether,  to  be 
followed  when  narcosis  is  further  advanced  by  the  exhibition  of  pure  ether 
from  a  Rendel's  mask,  with  which  the  anaesthesia  is  afterwards  kept  up 
throughout  the  operation. 

Preparation. — As  anaesthetics  are  best  taken  when  the  stomach  is 
empty,  their  administration  should  not  be  undertaken  within  three  or  four 
hours  of  a  meal.  When  possible,  it  is  best  to  arrange  for  operation  at  the  time 
when  a  meal  is  due — e.g.  about  the  hours  nine,  one,  four,  or  six.  As  children 
bear  badly  the  deprivation  of  food,  any  longer  interval,  besides  being 
unnecessary,  is  injurious,  making  the  patient  feel  faint.  A  feeble  child,  or 
one  kept  long  without  food,  should  be  given  some  liquid  nourishment  some 
little  time  before  operation. 

In  every  case  it  is  well  to  have  at  hand  chloroform,  ether,  and  A.C.E, 
mixture  ;  the  administrator  should  also  have  a  plentiful  supply  of  lint, 
tongue  forceps,  a  hypodermic  syringe,  nitrite  of  amyl  capsules,  sponges,  an 
electric  battery,  and  a  mouth-gag  with  a  sponge-holder.  These  latter  are 
occasionally  required  in  cases  of  vomiting. 

Before  beginning  the  administration,  examine  the  mouth  for  any  loose 
temporary  teeth  which  might  become  detached,  especially  if  a  gag  is  to  be 
used,  and  also  in  better-class  children  for  any  dental  regulating  plates  ; 
avoid,  if  possible,  alarming  the  patient,  for  with  a  struggling,  crying  child 
the  danger  of  giving  an  overdose  is  increased.  By  a  little  tact  most 
children  can  be  aneesthetised  without  any  crying,  even  when  inhalers  are 
used.  If  the  child  is  nervous,  let  it  sit  on  its  mother's  or  nurse's  knee.  If 
the  little  patient  is  not  undressed,  do  not  have  the  clothes  removed  until  it 
is  ansesthetised  ;  the  undressing  can  then  be  managed  without  alarming 
it.  Let  the  child  see  the  inhaler  or  lint  and  smell  it  before  any  anaesthetic 
is  put  on,  and  begin  with  a  very  weak  vapour.  During  the  administration, 
when  the  smell  is  objected  to,  incite  the  patient  to  '  blow  it  away.'  It  is  not 
absolutely  necessary  that  the  child  should  be  lying  down  in  the  early  stages  ; 
if  quiet  can  be  gained  by  letting  it  sit  up,  permit  this.  These  small  details 
are  of  importance,  as  there  is  no  doubt  that  to  a  highly  sensitive  child  the 
struggling  and  shock  of  being  'choked  off'  by  an  anaesthetic  may  have 
injurious    after-effects.       Should    the    child    cry,  go    on    steadily  with   the 


Ether.     Chloroform  821 

administration,  but  do  not  give  an  extra  quantity  or  'push'  tlTC  anaesthetic 
to  get  it  '  under'  the  quicker.  As  it  is  breathing  more  deeply  than  normal, 
rather  exhibit  less  of  the  antcsthetic,  and  so  avoid  all  chance  of  the  sudden 
inhalation  of  an  excessive  dose. 

Ether  when  given  alone  is  best  administered  by  a  Clover's  inhaler.  It 
should  be  given  slowly,  with  a  free  admixture  of  air.  In  nervous  subjects 
the  face  piece  may  be  applied  first,  and  when  the  patient  is  accustomed  to 
it,  the  ether  box  and  bag  may  be  added  and  free  respiration  into  the  bag 
established  before  ether  is  admitted.  Should  the  patient  become  highly 
excited  and  rough,  it  is  allowable  to  turn  on  a  stronger  vapour  and  hasten 
the  anaesthesia. 

When  possible  it  is  always  desirable  and  more  humane  to  begin  the 
anaesthesia  with  some  less  pungent  anaesthetic.  Of  these  nitrous  oxide  is 
the  best,  and  the  most  convenient  apparatus  is  Hewitt's  modification  of 
Clover's  inhaler.  Very  little  gas  is  required,  and  the  ether  should  be  turned 
on  before  the  nitrous  oxide  has  produced  any  muscular  disturbance.  The 
strength  of  the  ether  vapour  can  be  estimated  by  its  effect  on  the  pharynx  ; 
if  it  produces  swallowing,  or  catching  I'espiration,  it  is  too  strong,  and  a 
weaker  vapour  should  be  presented  to  the  patient,  as  it  is  important  not  to 
irritate  the  pharynx  and  lungs.  It  is  better  that  the  patient  should  breathe 
freely  a  weak  vapour  of  ether  than  have  a  strong  irritating  vapour  forced  on 
him.  The  onset  of  anaesthesia  is  indicated  by  the  signs  already  mentioned  ; 
of  these  an  important  one  is  the  absence  of  swallowing  or  irritation  when 
the  index  of  the  inhaler  is  turned  to  '  three'  or  'full.'  When  once  'under' 
a  very  little  ether  is  needed  to  maintain  narcosis.  Should  there  be  indica- 
tions of  excessive  secretion  of  mucus,  chloroform  or  A.C.E.  may  be  cautiously 
substituted  for  the  ether  ;  care  must,  however,  be  taken  that  in  the  deeper 
respirations  and  quicker  pulse  induced  by  the  ether,  an  overdose  is  not 
inhaled.  Failing  nitrous  oxide,  a  little  chloroform  or  A.C.E.  may  be  first 
given. 

Chloroform  is  most  conveniently  given  on  lint.  First  put  a  little  vaseline 
on  the  face  to  prevent  blistering  ;  place  the  fold  of  lint  over  the  nose  and 
mouth,  and  then  gradually  drop  the  chloroform  on  it.  When  the  patient 
objects,  coax  him  to  '  blow  it  away.' 

It  is  a  good  plan,  standing  on  the  patient's  right,  to  hold  the  lint  on  the 
nose  with  the  left  thumb  and  forefinger,  pressing  on  the  nasal  bones,  while 
the  third  and  fourth  fingers  spread  over  the  forehead,  feel  the  pulse  of  the 
anterior  temporal  artery,  and  steady  the  head  ;  the  right  hand  is  then  free 
to  drop  on  the  chloroform  and  control  any  movements.  In  dropping  the 
chloroform  hold  the  bottle  near  the  lint  ;  if  it  is  dropped  from  a  height,  it  is 
extremely  easy  for  a  little  to  get  into  the  eye. 

Hold  the  child  as  little  as  possible.  If  it  seizes  the  lint,  quickly  replace 
it  with  a  fresh  piece  rather  than  waste  time  strugghng  for  the  first ;  never 
try  with  chloroform  to  '  send  it  over  quickly.'  Each  inspiration  means  one 
dose  of  the  drug,  which  takes  effect  some  seconds  after  its  inhalation  ; 
therefore  remove  the  lint  at  the  .first  sign  of  anaesthesia,  or  the  patient  will 
inhale  several  unnecessary  doses.  The  quickness  with  which  children 
become  unconscious  has  been  referred  to.  It  occasionally  happens,  especially 
when  there  is  some  obstruction  to  respiration,  that  after  a  certain  degree  of 


822  Ancssthetics  for  Children 

unconsciousness  is  reached  the  patient  breathes  so  quietly  that  it  is  difficult 
to  induce  complete  narcosis,  and  nausea  with  feeble  circulation  is  produced. 
This  may  be  overcome  by  stimulating  the  respirations  by  rubbing  the  chest, 
pinching  the  jaw,  or,  better  still,  by  giving  a  little  ether. 

As  the  pain  during  an  operation  varies  with  the  tissues  cut,  it  is  not 
necessary  to  keep  the  patient  deeply  narcotised  throughout  the  operation, 
and  though  the  patient  may  wince  with  the  skin  incision,  the  remaining  steps 
of  the  operation  may  cause  no  signs  of  sensation. 

Should  there  be  coughing,  in  the  deep  inspiration  following  the  cough 
do  not  let  the  patient  inhale  too  much  chloroform  vapour,  and  be  careful 
not  to  mistake  the  general  jerking  of  the  limbs  caused  by  the  coughing  for 
voluntary  movements  requiring  more  chloroform.  It  is  occasionally  difficult 
to  abolish  reflex  movements  entirely  during  an  operation  on  the  skin,  and 
the  angesthetist  must  therefore  not  respond  too  readily  to  the  '  More  chloro- 
form, please,'  of  the  operator. 

Spasm  of  the  glottis  with  crowing  inspiration  is  very  common,  especially 
if  the  patient  is  not  quite  '  under '  or  is  beginning  to  have  nausea  ;  it  is 
generally  a  sign  of  imperfect  anaesthesia,  and  when  accompanied  by  such 
signs  as  rigidity  of  the  jaw  muscles,  contracted  or  slightly  dilated  pupils, 
and  a  good  pulse,  is  an  indication  for  more  of  the  anaesthetic  ;  the  spasm  is 
partly  relieved  by  pushing  forwards  the  jaw  with  the  neck  hyper-extended. 
As  previously  remarked,  pulling  out  the  tongue  with  forceps  does  not  remove 
the  spasm.  Such  treatment  is  rarely  required,  and  should  be  avoided  as 
much  as  possible,  as  being  liable  to  cause  unnecessary  after-pain  in  the  shape 
of  a  sore  tongue.  If  it  is  considered  advisable  to  keep  the  tongue  drawn 
out,  it  should  be  gently  held  out  with  a  pair  of  tongue  forceps,  or,  better 
still,  by  the  fingers  and  a  piece  of  lint.  The  lower  jaw  can  be  conveniently 
held  forwards  by  using  the  closed  forceps  as  a  lever,  the  upper  teeth  acting 
as  the  fulcrum,  care  being  taken  not  to  loosen  them. 

During  the  administration  the  same  rules  should  be  observed  with 
children  as  with  adults. 

When  once  the  child  is  '  under'  it  is  very  important  to  avoid  moving  it 
suddenly  or  roughly  ;  such  treatment  tends  to  cause  syncope.  This  caution 
is  especially  necessary  if  there  has  been  any  loss  of  blood  or  if  there  is  faint- 
ness.  Under  these  circumstances  never  allow  a  patient  to  be  raised  up  into 
a  sitting  or  semi-sitting  position  for  the  application  of  dressings.  This  can 
easily  be  avoided  by  drawing  the  patient  to  the  end  of  the  table  and 
supporting  the  body  so  that  the  head  and  shoulders  project  beyond  the 
table  ;  full  access  can  thus  be  gained  to  any  part  without  in  the  least  raising 
the  trunk.  We  have  seen  a  serious  attack  of  faintness  brought  on  by  the 
sudden  raising  of  the  head  and  shoulders  of  a  child  at  the  end  of  an  opera- 
tion in  which  a  considerable  amount  of  blood  had  been  lost. 

In  connection  with  this  it  is  important  to  remember  that  feeble  respira- 
tions are  not  always  associated  with  shock.  One  of  the  most  serious 
symptoms  of  cardiac  and  general  failure  is  deep  gasping  respiration 
accompanied  with  a  quick  running  pulse.  If,  in  a  patient  undergoing  a 
severe  operation,  ordinary  quiet  respiration  suddenly  gives  place  to  deep 
inspirations,  especially  if  they  are  of  a  gasping  character,  associated  with  a 
quick  pulse  and  dilated  pupil,  it  is  a  sign  of  the  onset  of  serious  if  not  fatal 


AncBsthetics  in  Special  Operations  823 

syncope.  This  is  not  as  common  in  children  as  in  acluUs,  liut  it  occurs  in 
them  under  similar  conditions.  It  is  due  to  sudden  aniemia  of  the  respi- 
ratory centre,  whether  caused  by  actual  loss  of  blood  or  cardiac  failure. 

Vomiting-,  if  the  stomach  is  empty,  can  be  overcome  by  giving  more 
chloroform  ;  otherwise  it  is  better  to  suspend  the  administration  until  the 
stomach  has  been  emptied,  and  then  to  resume  it  ;  turn  the  patient  well 
on  one  side  during  vomiting,  and  keep  the  mouth  and  pharynx  clear.  A 
patient  with  a  loaded  stomach  will  breathe  badly,  have  stertor,  and  present  a 
more  or  less  cyanotic  appearance.  Frequently  the  vomiting  will  be  preceded 
for  some  time  by  a  condition  in  which  the  patient  presents  a  feeble  pulse, 
irregular,  stertorous,  or  spasmodic  respirations,  and  more  or  less  cyanosis, 
which  is  improved  when  once  actual  vomiting  begins. 

Anaesthetics  in  Special  Operations. — There  are  practically  no 
conditions  under  which  an  anaesthetic  is  contra-indicated;  if  an  operation 
can  be  performed,  an  anaesthetic  can  be  given.  A  few  operations,  however,, 
require  special  notice. 

In  Tracheotomy  an  anaesthetic,  though  not  absolutely  necessary,  is  a 
distinct  advantage,  especially  where  it  is  desired  to  clear  membrane  from 
the  ti-achea.  The  danger  that  it  might  set  up  a  fatal  spasm  can  be  avoided 
by  giving  it  gradually  in  a  diluted  state  and  by  delaying  the  administration 
until  the  operator  is  quite  ready.  As  preparation  for  any  emergency,  it  is 
well  to  arrange  the  patient  on  a  definite  plan — e.g.  on  the  back,  with  the 
shoulders  and  back  of  the  neck  supported  by  one  firm  pillow  and  a  second 
smaller  one  under  the  occiput.  In  the  event  of  a  sudden  spasm  and  cessa- 
tion of  respiration  demanding  immediate  operation,  by  pulHng  away  the 
second  pillow  the  head  at  once  drops  backward,  making  prominent  the 
trachea  without  any  lifting  of  the  patient.  This  plan,  though  most  useful 
in  dealing  with  heavy  adults,  is  equally  valuable  in  children. 

Operations  on  the  Mouth. — In  all  operations  on  the  mouth  or  pharynx 
it  adds  materially  to  the  patient's  safety,  and  to  the  chloroformist's  comfort,, 
to  have  the  patient's  head  hanging  downwards  ;  either  hanging  over  the  end 
of  the  table,  or  with  the  neck  so  extended  over  pillows  that  the  vertex  of  the 
head  rests  on  the  table.  The  head  must  lie  supported,  or  the  weight  of  it 
hanging  on  the  thorax  tends  to  fix  the  chest.  This  position  keeps  the  larynx 
quite  free  from  blood,  which,  while  it  is  fluid,  will  escape  through  the  nostrils 
or  mouth,  or  collect  in  the  palate.  A  damp  towel  or  bathing  cap  should  be 
fixed  around  the  head  to  keep  the  hair  from  being  soiled.  If  the  patient  be 
properly  arranged  in  this  position,  the  risk  of  blood  entering  the  larynx,  even 
when  the  haemorrhage  is  excessive,  is  very  slight,  providing  the  patient  is 
well  '  under.'  In  all  cases  of  bleeding  from  the  mouth  it  is,  we  are  convinced, 
safer  to  have  the  patient  quite  msensible  and  to  keep  the  blood  from  the 
larynx  by  arranging  the  patient  in  a  proper  position,  and  by  the  use  of 
sponges,  than  to  trust  to  a  semi-conscious  patient  coughing  up  the  blood. 
In  the  latter  case  there  is  an  equal  risk  that  the  blood  may  be  sucked  into  the 
larynx,  and  with  a  struggling  partially  insensible  patient  it  is  more  difficult 
to  control  any  bleeding. 

As  regards  the  selection  of  the  anaesthetic,  the  fact  that  the  operation  is 
one  involving  the  mouth  or  throat  does  not  in  itself  confine  the  anaesthetic  to 
chloroform.   Mr.  Warrington  Haward  has  shown  that  ether  may  be  used  in  the 


824  Ancssthetics  for  Children 

operation  for  cleft  palate,  and  ether  is  constantly  given  in  operations  for  post- 
nasal adenoid  growths. 

In  cleft  palate,  chloroform  is  the  most  convenient  anaesthetic  ;  it  should  be 
given  on  lint  until  the  patient  is  '  under,'  and  the  administration  continued  by 
Junker's  inhaler,  by  which  means  the  operator  can  work  continuously 
without  being  interrupted  by  the  chloroformist.  If  respirations  are  feeble  it  is 
a  good  plan  to  apply  the  ether  mask  until  moderately  deep  narcosis  results, 
when  it  can  be  kept  up  with  the  Junker. 

In  the  operation  for  post-nasal  adenoid  growths,  an  anaesthetic 
(gas  and  ether  or  chloroform)  should  always  be  given.  The  patients  are 
longer  in  becoming  insensible  from  the  interference  of  the  adenoids  with 
respiration.  If  the  head  is  allowed  to  hang  downwards  and  moderately 
deep  narcosis  is  induced,  the  free  haemorrhage  is  never  any  real  trouble. 
In  laryngoscopic  examination,  chloroform  is  useful  for  abolishing  the  fear  of 
the  patient  ;  but  it  will  not  always  cause  sufficient  anaesthesia  to  permit  of 
the  larynx  being  manipulated  through  the  mouth.  In  one  case  of  laryngeal 
polypus  in  a  child  aged  six  years,  under  the  care  of  Dr.  Harris,  we  utterly 
failed  to  produce  anaesthesia  sufficiently  deep  to  permit  the  growth  to  be 
removed  by  the  mouth,  even  by  combining  the  cocaine  spray  with  the 
chloroform. 

In  empyema  cases  chloroform  is  best.  Care  must  be  taken  not  to  produce 
coughing  by  giving  it  too  strongly  at  first,  and  the  child  must  not  be  turned 
to  the  sound  side,  but  may  be  sat  up  or  turned  on  the  diseased  side,  as 
recommended  by  Mr.  Godlee. 

In  cases  of  trephining  the  spine,  chloroform  should  be  given.  The  best 
plan,  especially  if  there  is  paralysis  of  the  intercostals,  is  to  turn  the  patient 
right  on  to  the  face  and  support  the  body  on  pillows  in  the  following  way  : 
the  anterior  iliac  spines  rest  on  a  firm  sand  pillow,  an  ordinary  thin  pillow 
supports  the  chest,  and  the  forehead  rests  on  a  second  smaller  firm  sand 
pillow.  By  this  means  the  operator  gets  free  access  to  the  spine,  the  abdomen 
is  not  pressed  upon,  and  the  diaphragm  has  full  play,  while  the  mouth  and 
nose  are  supported  some  distance  from  the  table,  and  the  chloroform  lint  can 
be  slipped  under  the  nose  as  required  ;  any  secretion  flows  easily  out  of  the 
mouth. 

OperEitions  on  the  Bladder. — In  these  cases  it  is  important  to  have  the, 
patient  '  under '  before  injecting  the  bladder.  If  this  is  neglected  the 
manipulations  will  most  likely  set  up  spasm  of  the  glottis  and  straining, 
which  will  impede  the  inhalation  of  the  anjesthetic  and  delay  the  production 
of  anaesthesia. 

J%.ccideiits  are  of  a  similar  nature  to  those  which  occur  in  adults,  and 
should  be  treated  oh  similar  principles.  As  examples  of  the  various  kinds  of 
accidents  may  be  quoted  cases  in  which  an  attempt  is  made  to  ansesthe- 
tise  speedily  a  crying  child,  with  the  result  that  it  is  allowed  to  take  several 
deep  inspirations  of  a  highly  concentrated  chloroform  vapour,  and  so  obtains 
a  sudden  overdose  ;  in  other  cases  during'  deep  anaesthesia  the  dangerous 
symptoms  may  be  initiated  by  some  sudden  movement  of  the  child.  We 
have  seen  two  cases  of  this  class  when  the  patient  was  deeply  narcotised  for 
the  operation  of  cleft  palate  ;  the  sudden  raising  of  the  patient  produced 
symptoms    of    syncope.       In    unprepared    patients    the  embarrassment   of 


Accidents  under  AncBst/ietics  825 

respiration  caused  by  a  loaded  stomach  and  the  onset  of  vomiting  gives 
much  trouble.  The  patient  breathes  with  difficulty,  has  spasm  of  the  glottis, 
becomes  pale  and  slightly  cyanosed,  has  a  feeble  pulse,  &c.  ;  most  of  these 
symptoms  are  relieved  by  \omiting. 

Apart  from  mechanical  obstruction  to  respiration,  accidents  under 
anaesthetics  are  due  to  paralysis  of  the  respiration  or  circulation  or  both. 
Treatment  should  be  directed  to  restoring  these  functions.  For  this  purpose 
it  is  futile  to  expect  benefit  from  the  effect  of  external  stimuli,  as  these  pre- 
suppose an  irritability  of  the  tissue  which  in  severe  cases  is  absent.  The 
best  remedy  is  artificial  respiration  so  performed  that  pressure  is  made  over 
the  heart.  This  serves  the  treble  purpose  of  getting  air  into  the  lungs, 
stimulating  the  heart,  and  keeping  up  the  blood  pressure.  The  supply  of 
blood  to  the  brain  should  be  facilitated  by  having  the  head  dependent,  and 
an  artificial  circulation  can  to  a  slight  extent  be  kept  up  by  alternately  raising 
and  lowering  the  head. 

A  number  of  drugs  have  recently  been  suggested  as  cardiac  or  circulatory 
stimulants  under  such  circumstances — e.g.  liq.  ammon.  fort,  and  acid, 
hydrocyan.  by  inhalation  ;  and  ext.  suprarenal  capsules  and  nicotine  by 
hypodermic  injection.  All  these  labour  under  the  disadvantage  that  to  be 
effectual  a  certain  considerable  degree  of  circulation  must  be  present  for 
their  absorption  and  conveyance  to  the  heart,  &c.,  and  this  is  as  a  rule  absent. 
Of  all,  ammonia,  from  the  method  of  applying  it  by  inhalation  and  its  power- 
ful effect  as  a  cardiac  stimulant,  would  seem  most  likely  to  be  useful. 

The  main  reliance,  however,  must  be  placed  upon  efficient  artificial 
respiration.  The  battery  is  useful  only  as  a  means  of  producing  artificial 
respiration  by  stimulation  of  the  phrenic  nerves,  and  then  it  must  be 
combined  with  compression  of  the  chest. 


Calot's  operation. — The  revival  of  the  practice  of  forcibly  reducing  the 
deformity  resulting  from  destruction  of  the  vertebral  bodies  by  tuberculous 
disease  must  be  briefly  noticed,  as  the  method  has  been  to  some  extent 
employed  in  this  country,  and  more  largely  upon  the  Continent  and  in 
America. 

The  plan  consists  in  straightening  out  an  angular  curvature  by  combined 
traction  and  pressure  forcibly  applied.  That  it  is  possible  to  reduce  the 
deformity  by  this  means  in  cases  where  active  disease  is  going  on,  and  even 
in; some  instances  where  repair  has  taken  place,  there  is  no  doubt.  Whether 
the  treatment  is  reasonable  and  justifiable  is  quite  another  question.  When 
active  disease  is  going  on  it  can  hardly  be  considered  desirable  to  tear  and 
bruise  tissues  already  damaged  by  the  attacks  of  tuberculosis,  and  run  the 
risks  of  adding  septic  infection  to  the  existing  tuberculous  lesion,  nor  must 
the  dangers  of  causing  tuberculous  embolism  be  forgotten.  But  further  than 
this  a  wide  gap  is  necessarily  made  in  the  spine,  and  we  have  to  consider  how 
this  is  to  be  filled.  The  gap  is  lined  with  lacerated  tuberculous  tissue, 
and  is  filled  with  caseous  material,  recent  blood  clot,  and  probably 
fragments  of  carious  or  necrotic  bone.     These  are  not  tissues  likely  to  be 


826  AncESthetics  for  Childi^en 

effectual  in  satisfactorily  filling  up  the  chasm,  yet  they  are,  apart  from  a 
recurrence  of  the  deformity  and  coaptation  of  the  walls  of  the  gap,  the  only 
material  available  for  repair. 

Other  objections  to  be  raised  against  the  plan  are  the  dangers  of  injury 
to  the  spinal  cord,  of  rupturing  '  abscesses  '  or  collections  of  caseous  material, 
of  complete  severance  of  the  spinal  column,  and  of  lighting  up  a  fresh  out- 
break of  the  local  tuberculosis.  Such  are  the  objections  in  theory  to  the 
operation.  In  practice  the  record  of  mortality  and  bad  results,  though  very 
serious,  is  not  hitherto  so  bad  as  might  have  been  expected,  but  so  far  as  we 
are  aware  no  evidence  is  yet  forthcoming  that  any  repair  or  filling  up  of  the 
gap  by  new  bone  takes  place,  and  therefore  we  have  no  ground  for  believing 
that  the  restoration  of  shape  will  be  permanent. 

The  strongest  argument  in  favour  of  the  practice  is  that  it  is  said  to  have 
been  successful  in  some  cases  of  paraplegia  in  relieving  the  pressure,  but 
from  what  we  know  of  the  causes  of  paraplegia  in  spinal  caries  we  cannot 
expect  that  this  relief  will  be  anything  but  exceptional. 

On  the  whole  the  practice  is  to  be  looked  upon  as  wrong  in  principle,  and 
too  dangerous  and  uncertain  to  justify  any  further  resort  to  it  until  it  can  be 
shown  by  a  record  of  the  cases  already  operated  upon  not  only  that  the 
immediate  and  remote  dangers  are  not  great,  but  also  that  the  improve- 
ment in  position  is  permanent  and  the  subsequent  union  of  the  bone  secure. 
We  have  never  been  tempted  to  try  the  method. 


APPENDIX 


MODIFIED    MILK,    MILK    LABORATORY 

THE    WALKER-GORDON    LABORATORY, 

626    MADISON    AVKNUE,     NEW    YORK 


Per  Cent. 

REMARKS- 

Fat               

Number  of 

feeding's 

M  ilk-Sugar           

Albuminoids 

Amount  at 
each  feeding 

Infant's  age 

Infant's  weig 

Alkalinity  . .  . 

Heat  at 

Mineral  Matters  ... 

Total  Solids 

Water       

ht 

i 

100 

GO 

°F. 

Order  for. 


Date, 


Signature, 


If  the  physician  does  not  care  to  mention  the  especial  percentages,  he  can  ask  for 
percentages  which  will  correspond  to  the  analysis  of  human  milk,  and  he  can  then 
vary  any  or  all  of  these  percentages  later,  according  to  the  need  of  the  especial  infant 
prescribed  for. 


828  Diseases  of  Children 

Referen'CE  has  been  made  (p.  48)  to  the  milk  laboratories  established  in  Boston  and 
other  cities  of  the  United  States  (also  in  London — the  Walker-Gordon  Laboratory) 
for  preparing  and  modifying  cow's  milk  in  order  to  suit  the  varying  needs  of  infants 
and  children,  both  in  health  and  disease.  The  physician  writes  a  prescription 
stating  the  amount  of  fat,  milk-sugar,  proteids,  &c.,  required  in  the  infant's  food, 
and  also  the  amount  at  each  feeding  ;  the  prescription  is  dispensed  at  the  laboratory, 
and  delivered  at  the  house  daily  according  to  the  directions  given.  One  of  the 
most  important  points  in  connection  with  these  establishments  is  that  they  have 
control  of  the  milk  from  the  first ;  they  keep  their  own  cows,  not  purchasing  any 
milk.  Their  cows  are  selected,  fed,  and  cared  for  solely  with  reference  to  the 
employment  of  their  milk  for  infant  feeding,  and  the  health  of  the  animals  is  most 
carefully  looked  after.  The  milk  is  cooled  at  once  to  40°  F.,  and  kept  at  this 
temperature  till  used.  The  food  is  sent  out  in  separate  feeding  bottles,  read}' 
sterilized  or  pasteurized,  and  all  the  nurse  requires  to  do  is  to  warm  the  food  and 
fit  the  india-rubber  tube  to  the  bottle  when  the  infant  is  to  be  fed. 
A  specimen  of  a  prescription  form  is  given  on  page  48. 

"  Modified  Milk." — Feeding  of  infants  7-equiring  a  substitute  for  breast  milk. 
American  practice  in  the  vicinity  of  milk  laboratories  has  satisfied  itself  that 
"  modified  milk  "  is  the  most  successful  substitute  feeding.  In  round  statement, 
the  composition  of  cow's  milk  may  be  set  down  as  : 

Fats,  4  'fo. 

Sugar,  4  i. 

Albuminoids,  4^. 

High  average  breast  milk  may  be  set  down  as  : 
Fats,  4^. 
Sugar,  7  'jL 
Albuminoids,  2  ^. 

A  low  average  may  be  set  down  as  : 
Fats,  3  %. 
Sugar,  6  %. 
Albuminoids,  i  %. 

With  these  three  sets  of  figures  in  mind,  in  a  majority  of  cases  the  practitioner 
may  "modify"  the  proportions  of  fat,  sugar,  and  albuminoids  to  the  needs  of  the 
child,  changing  the  proportions  according  to  the  indications  ascertained  from  ob- 
serving the  nature  of  the  passages  and  the  general  condition  of  the  child.  His 
orders  for  varied  proportions  he  writes  in  a  prescription. 

For  a  newborn,  upon  the  third  day,  the  beginning  proportions  may  be  tempo- 
rarily lower  in  percentages : 

Fats,  2  $. 
Sugar,  5  or  6  ^. 
Albuminoids,  0.75  %. 

Furthermore,  with  these  figures  in  mind  it  is  not  impracticable  with  the  aid  of 
the  Babcock  cream-tester  and  the  sugar  solution  to  prepare  approximately  a  modi- 


Appendix  829 

fied  milk  in  a  home-made  laboratory.  Such  a  laboratory  is  in  use  in  two  of  the 
institutions  for  the  care  of  3'Oung  infants  in  New  York. 

It  is  the  earnest  hope  of  the  profession  of  America  that  the  feeding  of  infants 
may  be  kept  within  the  domain  of  physicians  and  without  necessary  reliance  upon 
the  made-up  foods  of  commercial  firms.  Cow's  milk  when  modified  to  the  propor- 
tions of  fats,  sugar,  and  albuminoids  found  in  breast  milk  offers  at  present  the 
most  available  and  practicable  infant  substitute  feeding.  For  exactness  in  modi- 
fication a  well-equipped  laboratory,  such  as  exist  in  Boston  and  New  York,  is 
requisite. 

Professor  Rotch,  of  Harvard  University,  has  taught  the  profession  to  think  in 
percentages,  and  has  brought  to  practical  completeness,  by  the  aid  of  the  Walker- 
Gordon  Laboratory,  prescription  writing  and  exact  modifying  of  milk. 

The  Pasteurization  of  Milk. — Pasteurization  consists  of  two  essential  opera- 
tions of  equal  importance,  (i)  Sterilization  at  68°  C.  =  155°  F.,  followed  by  (2) 
rapid  cooling  to  about  10°  C.  =  50°  F.  The  adoption  of  pasteurization  has  been 
due  to  our  knowledge  that  such  a  procedure  will  destroy  the  pathogenic  germs 
most  feared  in  milk  :  those  of  typhoid  fever,  diphtheria,  cholera,  and  tuberculosis, 
as  well  as  the  Staphylococcus  pyogenes  aureus,  the  Streptococcus  pyogenes,  the 
Coli  communis  and  the  Pneumococcus.  It  also  destroys  most  of  the  non-pathogenic 
bacteria.  On  the  other  hand  pasteurization  does  not  produce  those  chemical  changes 
in  milk  which  are  produced  by  sterilization  at  100°  C.  =  212°  F.,  and  which  render 
the  milk  less  digestible  and  less  nourishing. 

A  milk  pasteurizer  known  as  Dr.  Freeman's  apparatus  has  recently  been  placed 
before  the  profession.  This  apparatus  is  simple  and  inexpensive  and  produces 
in  the  milk  a  fairly  definite  temperature  of  68^  C.  =  155°  F.,  without  the  use  of  a 
thermometer,  and  is  provided  with  a  contrivance  for  rapid  cooling-.  The  apparatus 
consists  of  two  parts  :  a  pail,  and  a  receptacle  for  the  bottles  of  milk.  The  pail  is 
an  ordinary  pail  with  a  cover.  Encircling  the  pail  is  a  groove  to  indicate  the  level 
to  which  it  is  to  be  filled  with  water.  The  receptacle  for  the  bottles  of  milk  con- 
sists of  a  group  of  cylinders,  each  cylinder  large  enough  to  hold  one  bottle. 

In  using  the  apparatus,  the  pail  is  filled  to  the  level  of  the  groove  with  water 
and  placed  On  the  stove,  the  receptacle  for  the  bottles  of  milk  having  been  taken 
out.  The  bottles  are  filled  with  milk,  stoppered,  and  placed  in  the  cylinders  of 
the  receptacle.  The  space  surrounding  the  body  of  the  bottles  in  the  cylinders 
is  filled  with  cold  water.  When  the  water  in  the  pail  boils  vigorously,  the  pail 
is  taken  from  the  stove  and  the  receptacle  containing  the  bottles  of  milk  is  placed 
in  the  pail.  The  pail  is  then  covered  and  allowed  to  stand  on  a  table  or  the  floor 
for  three-quarters  of  an  hour.  During  this  time  an  equalization  of  temperature 
takes  place  between  the  hot  water  and  cold  milk.  During  the  first  ten  minutes  the 
temperature  of  the  milk  rises  to  about  68°  C.  =  155°  F.,  and  remains  there  during 
the  following  thirty-five  minutes.  At  the  end  of  three-quarters  of  an  hour  the 
cover  of  the  pail  is  removed,  the  receptacle  is  elevated  and  the  pail  is  placed  in  a 
sink  under  a  faucet,  from  which  cold  water  is  allowed  to  run  into  the  pail,  thus 
replacing  the  hot  water  and  cooling  the  milk.  In  twenty  minutes  the  milk  reaches 
about  the  temperature  of  the  surrounding  water  and  should  be  put  in  a  refrigerator 
until  used. 


830 


Diseases  of  Children 


Fig.  214. — Dr.  Freeman's  Pasteurizing  Apparatus. 

Pasteurized  milk  should  be  used  only  during  the,  twenty-four  hours  following- 
pasteurization. 

Intubation.* — The  views  expressed  on  page  347  are  not  so  favorable  as  those 
prevailing  in  America,  Germany,  France,  and  Hungary.  Intubation  is  capable,  in 
the  hands  of  a  skilled  operator,  supplied  with  the  proper  sizes  and  shapes  of  tubes, 
of  meeting  all  emergencies  which  the  advocates  of  tracheotomy  claim  for  the  cut- 
ting operation.  This  was  true  even  before  the  adoption  of  the  antitoxin  treatment 
of  diphtheria.  The  points  to  be  specially  considered  are  : 
When  to  operate. 
How        " 

How  to  remove  the  tube. 
When 

Dangers  and  difficulties  of  operation, 
wearing. 
"  "  "  removal  and  thereafter. 

Advantages. 
When  to  Operate. — W^hen  a  progressive,  unremitting  dyspnoea,  despite  all  pre- 
vious treatment,  allows  any  considerable  part  of  the  posterior  portion  of  the  lungs 
to  become   non-inflated,  when  the  labored  breathing  begins  to  produce  sensible 
exhaustion,  intubation  is  to  be  performed  promptly. 

How  to  Operate. — Wind  the  child  from  chin  down  in  a  light  blanket,  shoulders, 
arms,  and  hands  included.  Pin  the  blanket  closely  about  the  neck,  and  yet  do  not 
make  a  bulky  roll  to  interfere  with  depressing  the  introducer  handle.  In  this  way 
the  elbows  are  pinioned  to  the  side  and  the  hands  are  held  across  the  child's  abdo- 
men. • 

The  nurse  sitting  upright,  not  leaning  back,  should  grasp  the  child's  elbows 
firmly,  outside  its  winding  blanket,  of  course,  and  clasp  the  child's  legs  between 
her  knees,  making  sure  she  twines  her  own  about  the  legs  of  the  child.  Some 
prefer  to  stand  the  child  upon  the  nurse's  lap,  she  (the  nurse)  clasping  her  arms 


*  Extracts  from  a  paper  read  by  the  American  Editor,  before  the  British  IMedical  Associa- 
tion, Bristol,  England,  1894,  and  published  in  Brit.  Med.  Journal.,  Dec.  29,  1894. 


Appendix  831 

about  its  knees.  All  these  precautions  are  to  secure  the  child  in  a  firm  grasp,  to 
immobilize  it  without  interfering  with  tiie  expansion  of  its  chest,  and  may  be  taken 
without  causing  any  apprehension  or  excitement.  The  position  of  the  child  should 
be  as  though  it  hung  from  the  top  of  Us  head. 

The  physician  assisting  should  stand  behind  Uie  chair  of  the  nurse,  grasp  the 
child's  head  between  his  hands,  hold  it  firmly,  and  when  the  gag  has  been  inserted 
include  it  within  his  grasp  to  insure  its  firmness  and  steadiness.  The  operator, 
seated  or  standing  squarely  facing  the  child  and  nurse,  inserts  the  gag,  opens  the 
mouth  widely,  and  gives  the  handle  into  the  keeping  of  the  assistant.  The  intro- 
ducer, armed  with  the  proper-sized  tube,  is  supposed  to  be  threaded  and  at  hand. 

Next  he  inserts  his  index-finger,  hooks  up  the  epiglottis,  crowds  his  finger  to 
one  side,  passes  the  tube  past  it  till  it  engages  in  the  chink  of  the  glottis,  elevates 
the  handle,  gently  passes  the  tube  down  till  the  head  is  within  the  box  of  the  lar- 
ynx and  the  introducer  lies  crowded  upon  the  tongue.  He  then,  with  the  trigger, 
loosens  the  obturator,  holds  the  tube  with  the  left  index-finger  while  withdrawing 
the  obturator,  and  with  a  gentle  thrust  presses  the  tube's  head  well  into  the  larynx 
and  removes  the  finger  and  gag.  Just  here  let  me  emphasize  what  is  stated  above 
— keep  the  introducer  in  the  middle  line  ;  otherwise  the  obturator  will  pinch  in  the 
calibre  of  the  tube  and  drag  the  tube  with  it  as  it  is  withdrawn. 

The  handle  of  the  introducer  should  be  held  most  lightly  between  the  end  of 
the  thumb  and  the  fingers.  In  this  way  it  is  impossible  to  use  enough  force  to 
make  a  false  passage.  The  lines  and  angles  must  be  maintained  to  insure  quick 
intubation.  If  on  the  first  attempt  the  tube  is  not  successfully  placed  in  the  lar- 
ynx it  is  better  to  make  repeated  short  attempts  than  prolong  one. 

Having  placed  the  tube  in  the  larynx,  there  will  be  rattling  in  the  tube  on  first 
respiration  and  subsequent  cough  and  expectoration.  A  vigorous  cough  argues 
well  for  the  sensitiveness  of  the  parts,  and  for  evacuation  of  accumulations  below. 
The  gag  is  removed  as  soon  as  the  tube  is  in  place,  but  not  so  the  thread  ;  it  must 
remain  till  it  becomes  evident  that  all  obstruction  to  breathing  has  been  overcome, 
and  no  partially  detached  false  membrane  is  in  the  trachea  below  the  tube.  The 
thread  at  first  acts  as  an  inciter  to  cough,  which  is  desired  ;  ordinarily,  ten  minutes 
are  sufficient  time. 

Hoiu  to  Remove  the  Tube. — Place  the  child  in  the  position  for  intubation  as 
described  above.  Thrust  the  left  index-finger  past  the  epiglottis,  hook  it  up,  rest  the 
tip  of  the  finger  upon  the  two  arytenoid  cartilages  and  carry  the  extractor  point  to 
the  end  of  the  left  index-finger  at  the  pulpy  portion  generally  regarded  the  most 
delicately  tactile.  The  situation  is  then  as  follows  : — The  finger-tip  upon  the 
arytenoid  marks  the  posterior  boundary  of  the  glottis  in  the  median  line.  Now, 
if  the  extractor  point  be  carried  along  the  median  line  to  the  end  of  the  finger  and 
the  handle  be  elevated,  the  point  will  naturally  be  pried  foward  from  the  end 
of  the  left  index-finger  on  the  arytenoids,  into  the  aperture  of  the  tube.  Occasion- 
ally cases  are  found  in  which  the  epiglottis  hugs  so  closely  the  head  of  the  tube 
that  it  is  very  difficult  to  raise  it  and  keep  it  out  of  the  way.  This  is  liable  to 
occur,  especially  in  ascending  croup,  in  which  the  epiglottis  is  not  always  involved 
in  the  diphtheritic  process.  In  such  cases  the  extractor  would  be  guided  better 
with  the  left  index-finger  at  the  side,  as  in  intubation.     The  guard  screw  of  the 


832  Diseases  of  Children 

extractor-lever  should  be  carefully  set  to  avoid  injury  to  the  tissues  in  case  the 
extractor  jaws  should  be  opened  by  mistake  in  the  soft  parts  instead  of  in  the 
tube.  Many  operators,  both  in  Germany  and  America,  leave  the  thread  attached 
throughout  the  whole  time,  and  occasionally  a  tube  is  coughed  out  after  the  swell- 
ing releases  its  grip.  So  in  actual  experience  one  is  not  called  upon  to  extract 
so  often  as  to  intubate.     The  fact  remains  that  extubation  is  more  difficult. 

When  to  Remove  the  Tube. — This  depends  on  the  age  of  the  child  and  duration 
of  the  disease  before  intubation  became  necessary.  The  older  the  child  the  earlier 
the  tube  can  be  dispensed  with.  Estimating  the  maximum  of  the  disease  to  be 
seven  days,  five  days'  wearing  the  tube  is  considered,  on  an  average,  sufficient. 
The  use  of  antitoxin  has  diminished  the  time  of  sojourn  of  the  tube  to  forty-eight 
and  often  twenty-four  hours. 

Dangers  and  Difficulties  of  the  Operation. — In  the  hands  of  an  experienced 
operator  there  are  practically  710  dangers  to  life  at  the  time  of  operation. 

A  few  authentic  cases  of  pushing  down  membrane  before  the  entering  tube 
have  been  recorded.  Expert  intubation  according  to  latest  practices  presupposes 
that  the  thread  has  been  left  attached,  and  therefore  easy  immediate  removal  is 
possible.  This  experience  with  loose  pseudo-membranes  occurs  more  often  late  in 
the  disease,  and  in  reintubations. 

To  the  inexperienced  there  are  many  dangers  :  (i)  asphyxia  from  prolonged 
attempts ;  (2)  laceration  of  the  parts,  false  passages,  etc.  The  explanation 
usually  given  to  those  two  most  common  accidents  is  "pushing  down  false  mem- 
brane." So  called  syncopal  attacks  are  simply  lesser  attacks  of  asphyxia.  Con- 
vulsions are  recorded,  and  instruments  have  been  broken  in  intubation. 

An  experienced  operator  may  encounter  two  difficulties  : 

1.  The  point  of  the  tube  may  enter  one  of  the  ventricles  of  the  larynx.  This 
is  not  common,  for  the  original  disease  usually  fills  and  obliterates  these  cavities. 
Such  obstruction,  however,  does  occur.  It  may  readily  be  seen  how  an  inexpert, 
sure  that  his  tube  and  handle  were  exactly  in  the  middle  line,  might  force  his  tube 
into  the  tissues  of  the  neck.  He  certainly  has  but  to  remember  the  cardinal 
points  of  advice,  and  he  will  use  most  gentle  pressure  ;  he  need  but  look  at  the 
light  introducing  instruments  to  appreciate  that  they  are  for  delicate  work. 

2.  The  second  difiiculty  or  obstruction  that  an  experienced  operator  may  meet 
in  intubation  is  subglottic  stenosis — or  what  is  so  often  described  as  "oedema." 
The  narrowest  part  of  the  respiratory  ways  is  the  cricoid  ring.  This  fact,  so  far 
as  I  know,  came  to  light  for  the  first  time  in  Dr.  O'Dwyer's  early  investigations 
in  intubation.  If  the  head  of  an  intubation  tube  be  forcibly  crowded  down  from 
above,  it  may  pass  the  vocal  bands,  and  yet  resist  all  effort  at  the  cricoid  ring. 
Given  a  resisting  cartilaginous  ring  lined  with  mucous  membrane,  we  have  the 
very  elective  conditions  for  stenosis.  Fortunately,  the  swelling  and  infiltration 
are  not  often  extensive  enough  to  cause  serious  obstruction,  but  may  be.  Opera- 
tors come  upon  cases  where  the  properly  selected  tube  surely  passes  into  the 
larynx,  and  yet  encounters  resistance — even  "  creeps  back,"  as  someone  says, 
"  like  an  oiled  cork  in  a  bottle."  If  one  is  sure  of  the  diagnosis,  and  a  proper 
size  fails,  a  smaller  tube  may,  with  moderate  pressure,  be  introduced.  This  is  the 
only  condition  where  force  is  justified  in  intubation. 


Appendix 


833 


Dangers  and  Diffictdties  of  Wearing. — i.  The  tube  may  become  obstructed 
by  loosened  plaques  of  false  membrane.  This  constitutes  the  one  important 
danger  in  wearing  an  intubation  tube.     It  is  easy  to  understand  that  X'SlX^^  plaques 

may  become  loosened  and  detached  in  the 
trachea,  especially  after  several  days  of  the 
disease. 

A  detached  plaqtie  may  act  like  a  valve  at 
the  tube's  lower  end,  closing  on  expiration, 
opening  on  inspiration  till  the  lungs  become 
quite  distended  from  accumulated  air. 

At  this  point  let  me  interject  the  symptoms 
of  loose  membrane  : — (i)  croupy  character  of 
cough  (tube  being  in)  ;  (2)  flapping  sound  ;  {3) 
most  important,  sudden  obstruction  to  outgoing 
air,  especially  during  coughing. 

Most  continental  operators  loop  the  thread 
about  the  ear,  protecting  it  along  the  cheek  with 
rubber  adhesive  plaster,  and  leave  it  throughout 
the  wearing  of  the  tube.  This  is  advisable  out- 
side of  hospitals,  with  beginners,  and  in  case 
loosening  pseudo-membrane  is  suspected  in  the 
trachea.  Possibly  mucus  may  gradually  collect 
in  the  tube,  of  such  a  tenacious  quality,  espe- 
cially in  mouth-breathers  suffering  from  high 
temperature,  that  it  becomes  an  embarrassment 
or  even  danger. 

Short  Tubes  {loose  tnembrane  or  foreign-body 
tubes.') — They  are  short,  hollow  cylinders  of 
large  calibre — short  enough  not  to  push  down 
the  tracheal  membrane,  yet  long  enough  to  reach 
below  the  cricoid  stenosis  and  large  enough  to 
permit  masses  to  pass  through  them. 

Occasionally  a  long  tube  loosens  the  upper 
attachment  of  a  tracheal  cast  and  crumples  it 
into  a  wad  below  the  end  of  the  tube.  The 
usual  result  is,  as  would  be  expected,  apncea. 
Immediate  removal  of  the  tube  is  commonly 
followed  by  either  expulsion  of  the  cast  or  other 
disposal  of  the  mass  in  the  comparatively  large 
trachea.  At  this  point,  when  the  long  tubes  have  failed  to  give  relief,  the  short 
cylindrics  become  of  temporary  service. 

These  tubes  are  of  various  sizes,  seven  in  number.  Since  they  have  no  reten- 
tion swell  it  is  necessary  to  use  the  largest  size  possible,  wedging  it  into  the  larynx, 
and  for  obvious  reasons  in  the  line  of  pressure,  not  leaving  them  more  than  a  few 
hours  in  place.  They  require  a  special  introducer  with  long  curve  in  order  to  carry 
the  short  tube  well  through  the  cricoid  constriction  before  withdrawing  theobcurator. 


Figf.  215.— Short  large  calibre  tubes 
(loose  membrane  or  foreign-body 
tubes). 


834  Diseases  of  Childreji 

In  short,  to  allow  the  expulsion  of  loose  membrane  from  the  trachea,  the  largest 
possible  hollow  cylinder  is  passed  through  the  narrowed  larynx,  allowed  to  remain 
for  a  little,  and  removed  as  soon  as  the  resulting  cough  has  expelled  the  foreign 
body  requiring  its  insertion. 

2.  Ulceration  from  too  large  a  tube  making  pressure  within  the  cricoid  ring, 
and  ulceration  at  the  lower  end  of  the  tube.  The  former  can  be  of  a  serious 
nature,  destroying  the  cartilage  ;  the  latter  is  superficial  and  of  little  import.  Ul- 
ceration within  the  cricoid  is  due  to  improper  size  ;  ulceration  below  to  improper 
construction  of  tube. 

Properly  constructed  tubes  are  difficult  to  describe,  more  difficult  to  secure  from 
a  maker,  even  if  a  most  faithful  and  conscientious  servant.  But  one  maker  in 
this  world  has  succeeded  in  making  tubes  that  embody  all  the  ideas  of  the 
inventor. 

Feeding  an  Intubated  Patient. — There  is  one  disadvantage  after  operation  : 
feeding  is  difficult.  The  larynx  is  sore.  Many  times  it  is  sorer  because  of  the  inex- 
perience of  the  operator.  The  less  the  larynx  is  bruised  in  intubation,  the  less  the 
child  will  dread  the  clasp  of  the  pharyngeal  muscles  in  the  act  of  deglutition.  The 
fact  remains  that  there  is  more  or  less  difficulty  in  swallowing,  both  from  pain  and 
cough.  The  latter  arises  from  fluids  entering  the  trachea,  though  many  patients 
acquire  the  accomplishment,  and  learn  to  swallow  very  well.  The  method  of  feed- 
ing adopted  by  Dr.  Casselberry,  of  Chicago,  has  very  much  relieved  the  situation. 
The  child  is  inclined,  head  down,  so  that  it  swallows  up-hill,  and  any  fluid  that 
may  get  into  the  tube  in  the  act  of  deglutition  quickly  gravitates  out  again.  The 
directions  are  as  follows  : — Place  the  child  across  the  nurse's  lap,  bend  the  head 
well  down,  and  feed  either  with  a  spoon  or  through  a  nursing  bottle.  At  first 
these  patients  object,  but  when  they  learn  that  by  so  doing  they  can  swallow  with- 
out coughing  they  give  no  further  trouble. 

Medication  can  be  continued  after  intubation  as  well  as  before. 

Danger  of  Remo7>al  and  Thereafter. — If  the  tube  is  removed  on  the  fifth  day 
in  a  case  having  an  average  fair  course,  there  is  little  or  no  danger.  The  operator 
should  remain  half  an  hour.  If  in  this  time  there  has  been  coughing  and  clearing 
of  the  throat  and  trachea  and  no  loose  pseudo-membrane  remains,  and  no  dyspnoea, 
there  will  be  no  sudden  urgent  necessity  of  rapid  reintubation.  Even  yet  it  is 
deemed  desirable  to  be  within  easy  call  for  some  hours. 

I  once  considered  I  had  on  an  average  four  hours'  leeway,  but  exceptionally 
prompt  aid  was  needed  sooner,  and  a  few  cases  needed  reintubation  twelve  and 
twenty-four  hours  afterwards.  Whether,  pressure  removed,  the  mucous  membrane 
becomes  quickly  congested,  or  whether  muscular  spasm  sets  in,  or  membrane 
reforms,  I  know  not,  but  I  have  learned  to  respect  the  emergency  of  the  first 
twelve  hours  after  removal  of  the  tube,  especially  if  it  be  a  premature  removal. 

Retained  Tubes  {Laryngeal  Canutes). — Rarely  it  is  necessary  to  reinsert  a  tube 
many  times.  The  child  may  get  along  half  a  day  or  two  days  and  yet  require  the 
reintroduction.  If  the  tube  is  not  of  proper  anatomical  conformity  it  may  cause 
granulations  about  the  head.  To  relieve  this  and  cure  the  condition,  a  special 
tube  has  been  devised,  naving  a  prolonged  or  built-up  head.  (See  Fig.  216.)  It 
rides  above  and  causes  pressure  upon  the  granulations,  with  consequent  absorption. 


Appendix 


835 


Fig.    216.— Built-up  head 
for  granulations. 


Finally,  not  to  recapituhite  the  literature  of  the  subject,  I  may  mention  advan- 
tages.    First  of  all,  parents  will  consent. 

It  is  a  bloodless  operation  ;  no  cutting,  no  anaesthetic, 
and  this  means  much  to  the  friends.  It  is  quickly  per- 
formed, requires  no  trained  assistants  or  trained  attend- 
ants (it  is  trained  operators  that  are  needed).  The  air 
inspired  is  warmed  and  moistened  through  natural  pas- 
sages. Results  are  equal  to  or  rather  better  than  those 
of  tracheotomy  under  similar  circumstances,  whether  in 
hospital  or  outside. 

Finally,  since  the  successful  employment  of  antitoxin 
treatment  for  diphtheria  the  average  duration  of  laryngeal 
stenosis  has  been  so  shortened  that  there  seems  no  longer 
any  ground  for  contention  as  to  which  is  the  preferable 
method  of  tiding  past  the  urgent  symptoms  of  dyspnoea. 
As  Professor  von  Ranke,  of  Munich,  proclaimed  to  the 
British  medical  profession  in  London,  "  the  time  has  come 
when  it  should  be  upon  a  man's  conscience  to  leave  a 
scar  upon  a  child's  neck,  for,  with  the  employment  of 
healing  serum  there  remains  no  excuse  for  tracheotomy 
in  diphtheria." 

Rickety  Deformities  (p.  208). — The  transverse  thoracic  furrow,  with  the  pro- 
jection of  the  ribs  forming  the  lower  edge  of  the  thorax,  so  very  common  in  severe 
cases  of  rickets,  is  often  associated  with  more  or  less  kyphosis  of  the  dorso-lumbar 
spine.  All  of  these  conditions  can  be  very  much  improved  by  applying  a  light  steel 
spinal  brace  to  hold  the  spine  erect  and  draw  back  the  shoulders.  Over  this  brace 
is  applied  a  corset  made  of  drill,  which  exerts  pressure  on  the  lower  projecting  ribs 
only,  and  limits  abdominal  respiration.  Thoracic  respiration  is  then  developed  by 
inspiratory  exercises.  The  result  will  repay  the  surgeon  for  the  persistent  work 
necessary,  as  the  writer  has  seen  in  a  number  of  cases. 

Curvature  of  the  neck  of  the  femur.  Coxa  Vara  (p.  211). — A  number  of  cases  of 
this  deformity  have  been  recorded  here  already  by  Curtis,  Whitman  and  others,  and 
it  seems  likely  that  when  more  attention  is  directed  to  the  condition  our  experience 
will  be  similar  to  that  of  Hofmeister  and  other  German  surgeons,  who  have  found 
that  the  deformity  is  not  very  uncommon.  It  is  produced  by  the  weight  of  the 
body  and  diminished  resistance  in  the  bone.  It  is  observed  in  two-thirds  of 
the  cases  during  childhood,  and  in  the  remaining  third  at  the  age  of  puberty.  The 
affection  starts  with  pain  in  the  hip  and  limping  ;  at  first  in  consequence  of  a  long 
walk  or  great  fatigue  ;  later,  after  a  moderate  walk  ;  ultimately  no  work  is  possible. 
Function  is  especially  impaired  in  bilateral  cases.  The  disease  runs  its  course  with 
periods  of  remission  and  exacerbation.  In  two  or  three  years  the  pain  ceases,  and 
there  remains  as  a  final  result  an  actual  shortening  of  the  limb,  the  great  trochanter 
being  above  Nelaton's  line.  There  is  diminished  abduction  and  inward  rotation. 
The  limb  rests  in  a  position  of  outward  rotation,  and  the  patient  can  produce 
exaggerated  rotation  in  this  direction.  The  walk  is  in  consequence  characteristic, 
and  when  the  patient  wants  to  assume  a  kneeling  position  he  is  obliged  to  cross 


836 


Diseases  of  Children 


his  legs.  The  exact  point  of  this  incurvation  is  on  the  under  side  of  the  neck  and: 
a  Httle  posteriorly,  which  explains  the  elevation  of  the  trochanter  and  the  outvs^ard 
rotation  of  the  limb.  A  large  number  of  so-called  obscure  cases  of  coxitis  are 
really  this  affection.  The  diagnosis  is  important  with  reference  to  the  question  of 
early  excision,  sometimes  recommended  in  hip  disease.  Rest  will  soon  stop  the 
pain.  Then  continuous  extension,  massage,  and  exercise  may  benefit  some  cases. 
The  neck  of  the  bone  should  certainly  be  relieved  from  the  weight  of  the  body  by 
means  of  a  hip-splint  or  axillary  crutches,  during  the  progressive  stage.  No 
promises  should  be  made  of  diminishing  the  amount  of  curvature  of  the  bone 
found  when  treatment  is  commenced. 

Shaffer  (p.  210)  favors  supporting  the  kyphotic  spine  in  severe  cases  of  rickets 
during  the  progressive  stagfe  in  order  to  secure  bone-growth  in  the  normal  planes. 
In  this  way  not  only  can  we  readily,  and  without  discomfort,  correct  the  evident 
kyphosis,  but  also  correct  or  prevent  the  development  of  lateral  curvature,  since 
many  cases  of  this  curvature  are  dependent  upon  a  rickety  condition  and  develop 
very  early  in  life. 

The  splint  most  commonly  used  in  New  York  for  knock-knee  and  bow-legs  is 
shown  in  Fig.  217.  The  jointed  apparatus  is  efficient,  since  leverage  is  applied 
whenever  weight  is  borne.  It  also  favors  muscular  development,  and  allows  a 
more  graceful  gait.  A  pelvic  band  may  be  added  to  control  the  ppsition  of  the 
feet  if  required.  These  braces  are  somewhat  expensive,  but  at  the  New  York 
Orthopaedic  Hospital  this  objection  is  met  by  allowing  the  patients  to  paj^  for 
them  on  the  instalment  plan.  The  Knight  brace  (Fig.  218)  for  bow-legs,  and 
the  Thomas  knock-knee  brace,  are  also  largely  used.  These  deformities  can  be 
more  quickly  corrected  if,  in  addition  to  the  application  of  the  splints,  the  limbs, 
be  bent  by  manual  pressure  towards  their  normal  position  several  times  each  day.. 


Fig.  217.— New  York  Ortho- 
paedic Hospital  Brace  for 
Knock-knee  and  Bow-legs. 


Fig.  218. — Knight's  Bow-leg- 
Brace. 


Fig.  219. — Boston  Children's 
Hospital  Brace  for  Bow- 
legs. 


Appendix  837 

The  pressure  should  be  as  great  as  the  child  will  bear  without  crying,  and  should 
be  maintained  a  minute  or  two,  then  relaxed  and  reapplied  several  times.  In  the 
very  slight  grades  of  deformity  these  forcible  intermittent  pressure-exercises  may 
be  sufficient  to  cure  without  the  use  of  braces. 

In  the  Children's  Hospital  in  Boston,  the  apparatus  in  common  use  for  bow-legs 
(Fig.  219)  is  a  light  but  rigid  steel  upright,  jointed  at  the  ankle,  attached  below  to 
the  sole-plate  of  the  shoe.  It  runs  up  the  inside  of  the  limb  nearly  to  the  origin  of 
the  adductor  muscles  and  is  then  bent  forward  and  upward  and  curved  to  fit  into 
the  groin  and  come  up  as  far  as  the  posterior  part  of  the  dorsum  of  the  ilium. 
Leather  pads  opposite  the  greatest  convexity  of  the  curve  draw  the  limb  over  to  the 
upright.  For  knock-knee  a  similar  apparatus  is  used,  but  is  applied  on  the  outer 
side  of  the  limb,  and  at  the  level  of  the  trochanter  the  upright  is  bent  backward 
and  upward  to  lie  against  the  upper  part  of  the  buttock.  By  fastening  the  upper 
ends  together  the  position  of  the  feet  can  be  controlled. 

For  extreme  deformity  powerful  correcting  apparatus  have  been  devised  by 
^hdSiex  {American  Journal  flf  Obstet7-ics,  etc.,  vol.  xiv. ,  No.  iii. ). 

Whether  a  case  will  require  operative  treatment  depends  more  upon  the  flexibil- 
ity of  the  bones  and  the  laxity  of  the  ligaments  than  upon  the  age  of  the  child  or 
the  amount  of  deformity.  Anterior  curvatures  of  the  tibia  have  seemed  to  the 
writer  the  most  intractable  to  mechanical  treatment,  and  generally  require  an  oper- 
ation for  their  correction  (see  also  Bradford  and  Lovett,  "  Orthopaedic  Surgery," 
p.  682). 

In  America,  Macewen's  operation  (p.  221)  for  genu-valgum  is  chiefly  em- 
ployed. MacCormac's  modification,  in  which  the  chisel  is  used  upon  the  outer 
side  of  the  limb  and  a  green-stick  fracture  produced  on  the  inner  side,  is  also 
thought  well  of.  In  any  case  the  practice  is  to  wait  until  the  active  stage  of  the 
disease  is  past  before  operating.  The  saw  is  almost  never  used  here.  In  general 
osteoclasis  is  not  so  much  in  favor  as  osteotomy.  Rizzoli's  or  Grattan's  osteoclasts 
are  those  most  used. 

The  ambulatory  treatment  of  fractures  and  osteotomies  as  recommended  by 
Bardeleben,  "Korsch,  Albers,  Krause,  Dollinger,  etc.,  has  not  as  yet  received 
enough  attention  in  this  country  to  report  upon  its  usefulness. 

Lateral  Curvature  of  the  Spine.  Early  Onset  (p.  223). —  In  a  study  of  two 
hundred  and  twenty-nine  cases.  Ketch  (New  York  Medical  Record,  April  24,  1886) 
found  (i)  that' this  curvature  is  principally  a  disease  of  childhood,  and  may  be  either 
congenital  or  acquired  ;  (2)  that  puberty,  except  as  a  concomitant  occurrence,  which 
may  by  its  attendant  circumstances  increase  it  or  bring  it  into  unusual  prominence, 
has  no  direct  causative  influence  ;  (3)  that  lateral  curvature  should  be  looked  for 
early  in  life,  and  as  a  factor  in  treatment  the  early  inspection  of  children's  spines 
becomes  most  important  toward  the  prevention  of  the  deformity. 

Bradford  and  Lovett  also  ("  Orthopsedic  Surgery,"  p.  106)  recognize  its  appear- 
ance at  an  earlier  age  than  is  usually  supposed. 

Treatine7it  (p.  223). — Shaffer  relies  largely  in  cases  of  rotary  lateral  curvature 
on  an  exercise  partly  active  partly  passive.  Pressure  is  made  by  the  operator's 
hand  just  under  the  greatest  convexity,  in  a  direction  inward,  forward,  and  up- 
ward, the  opposite  shoulder  being  elevated  at  the  same  time.     The  patient  bends- 


838  Diseases  of  Children 

over  the  hand  exerting  the  pressure  and  untwists  the  spine  as  much  as  possible. 
The  counter-pressure  is  exerted  below  by  the  weight  of  the  pelvis  and  limbs,  and 
above  by  the  weight  of  the  upper  part  of  the  thorax  and  head,  increased,  if  neces- 
sary, by  pressure  from  the  operator's  hand,  which  is  being  used  to  elevate  the 
shoulder  opposite  the  projecting  ribs.  In  giving  the  exercise  the  patient  swings 
obliquely  forward  and  backward,  and  at  every  backward  swing  the  pressure  is  ap- 
plied after  the  body  passes  the  perpendicular.  The  patient  is  also  encouraged  to 
swing  from  rings  hung  at  unequal  heights,  so  as  to  overcorrect  the  drooping  shoul- 
der. These  exercises  are  given  once,  twice,  or  three  times  a  day  for  from  five  to 
twenty  minutes.  Sayre  {^Ne-iv  York  Medical  Journal,  November  17,  1888)  advises 
the  following  movements,  which  are  very  similar  to  those  of  Bernard  Roth  ("Treat- 
ment of  Lateral  Curvature  of  the  Spine,"  London,  1889)  and  are,  with  modifica- 
tions, those  most  generally  used  in  the  United  States.  The  various  exercises  are 
repeated  tliree  times  each  at  the  commencement  and  later  on  a  greater  number  of 
times. 

"The  patient  lies  prone,  the  arms  at  right  angles  to  the  trunk,  palms  down,  face 
turned  to  the  convex  side,  and  the  back  as  straight  as  possible.  The  patient  supi- 
nates  the  hands,  throws  the  scapulas  well  back,  raises  the  hands  from  the  floor 
and  lifts  the  trunk,  while  the  surgeon  holds  the  feet  down.  The  breath  should 
not  be  held  during  any  of  these  exercises,  but  the  patient  should  breathe  naturally. 
If  necessary  to  secure  this,  make  them  count  out  loud  while  exercising. 

With  hands  behind  the  head,,  the  patient  raises  the  elbows  from  the  floor,  and 
raises  the  trunk  as  before,  the  feet  being  held  by  the  surgeon. 

With  the  hands  behind  the  head  and  the  elbows  raised,  the  body  is  swayed  to- 
ward the  convex  side,  the  patient  trying  to  "pucker  in"  the  bulging  ribs  and  not 
to  bend  "in  the  lumbar  concavity.      The  feet  are  fixed  as  befoi-e. 

With  the  arm  on  the  side  of  the  convexity  under  the  body,  the  other  arm  over 
the  head,  the  heels  fixed,  the  patient  raises  the  trunk  from  the  floor. 

Sometimes  the  arm  on  the  side  of  the  concavity  is  put  on  the  opposite  buttock, 
while  the  patient  raises  the  trunk.  Sometimes  the  arm  on  the  convex  side  is 
put  on  the  buttock,  and  in  cases  of  marked  lordosis,  with  great  stooping  of  the 
shoulders,  both  hands  are  put  on  the  buttocks  while  the  patient  raises  the  trunk. 

The  patient  now  lies  on  the  back,  arms  at  the  sides,  palms  up,  and  lifts  first 
one  foot  in  the  air,  while  the  surgeon  makes  resistance  graduated  to  the  patient's 
power  ;  repeated,  say,  five  times.  The  same  is  done  with  the  other  foot,  and  then 
with  both.  The  feet  are  next  separated  and  then  brought  together  once  more  while 
the  surgeon  resists.  Each  leg  then  describes  a  circle,  first  from  within  out,  then 
from  without  in. 

If  there  is  special  weakness  at  the  ankles,  with  a  tendency  to  flat-foot,  the  pa- 
tient flexes  the  foot  and  extends  it  against  resistance,  and  turns  the  sole  of  the  foot 
■toward  its  neighbor,  the  surgeon  resisting,  and  it  is  then  forcibly  everted  again  by 
the  surgeon,  the  patient  resisting. 

The  patient  now  lifts  the  arms  from  the  sides,  passing  perpendicularly  to  the 
floor  till  they  are  stretched  as  far  beyond  the  head  as  possible,  and  then,  going  at 
.right  angles  to  the  trunk  and  parallel  with  the  floor,  returns  them  to  the  sides, 
.palms  up. 


Appendix  839 

While  the  heels  are  held,  the  patient  rises  to  the  sitting  position,  hands  at  the 
sides  ;  then  she  rises  from  the  floor  with  the  hands  behind  tiie  head  and  the  elijows 
at  right  angles  to  the  trunk. 

The  patient  now  stands  with  the  heels  together,  toes  turned  slightly  out,  hands 
behind  the  head,  elbows  at  right  angles  to  the  trunk  :  then  rises  on  tip-toe,  bends 
the  knees  and  hips,  keeping  the  back  as  straight  and  erect  as  possible,  and  rises  up 
once  more.  With  the  arm  on  the  concave  side,  high  above  the  head,  the  arm  on 
the  convex  side  at  right  angles  to  the  body,  she  rises  on  tip-toe,  bends  the  hips, 
knees,  and  ankles  so  as  to  squat,  then  rises  and  stands.  All  this  time  care  must  be 
taken  to  push  the  body  as  straight  as  possible,  and  gradually  educate  the  patient  to 
hold  it  so  without  wiggling  during  these  movements. 

Let  the  patient  practise  walking  in  these  positions,  both  on   the  flat  foot  and 
lip-toe,  and  also  step  high  as  if  walking  up-stairs.      With  the  palm  of  the  patient's- 
hand  on    the  convex   side  against    the  ribs,  pushing   them   in,  the  hand  on  the  con- 
cave side,  she  pushes  a  slight  weight  up  in  the  air,  while  the  body  swings  so  as  to  ■ 
straighten  out  the  curves. 

Sit  behind  the  patient,  fix  her  thighs  with  your  knees,  while  she  holds  both  arms 
above  the  head  and  bows  toward  the  floor,  keeping  her  knees  stiff  while  you  keep 
her  ribs  as  straight  as  possible  with  your  hands. 

With  the  arm  on  the  concave  side  across  the  top  of  the  head,  and  the  arm  on 
the  convex  side  around  in  front  of  the  abdomen,  the  patient  bends  to  the  convex 
side  through  the  ribs,  and  7iot  through  the  waist. 

The  patient  sitting  with  the  back  toward  the  surgeon,  the  latter  pushes  one 
hand  against  the  most  projecting  part  of  the  convexity,  and,  with  the  other  hand 
passed  under  the  shoulder  of  the  concave  side,  straightens  out  the  curve  as  much 
as  possible,  the  hand  on  the  "bulge"  acting  as  a  fulcrum  in  straightening  the 
curve. 

The  patient  sits  on  a  stool  in  front  of  the  surgeon,  who  fixes  the  pelvis  with  his 
knees.  The  patient  then  twists  the  projecting  shoulder  to  the  front  while  the  sur- 
geon holds  the  elbows,  which  are  at  right  angles  to  the  trunk,  the  hands  being  be- 
hind the  heacf,  and  makes  resistance.  '  In  the  same  position  the  patient  swings  for- 
ward and  back,  swinging  through  the  hips,  keeping  the  back  stiff,  and  not  bending 
in  the  waist. 

The  patient  pushes  in  the  ribs  on  the  convex  side  with  the  hand,  and  pushes  up 
with  the  hand  on  the  concave  side,  the  same  as  when  standing.  She  also  lifts  the 
arm  on  the  concave  side  up  at  right  angles  with  the  body  while  holding  a  weight. 

In  cases  of  round  shoulders,  windmill  motions  of  both  arms  and  to-and-fro 
movements  of  the  head  against  resistance  are  advisable. 

The  patient  lies  prone  on  the  couch,  all  the  body  above  the  waist  projecting 
from  it,  while  the  surgeon  holds  the  heels.  With  the  hands  behind  the  head,  the 
elbows  thrown  back,  the  body  is  bent  toward  the  floor,  then  raised  up  ;  later  on, 
resistance  is  made  by  the  surgeon.  The  patient  lies  on  the  concave  side  and 
rises  up  laterally.  The  patient  lies  with  the  convexity  on  the  edge  of  the  couch,  and 
hangs  off  as  far  and  as  long  as  possible. 

One  of  the  best  exercises  for  removing  the  curve  is  for  the  patient  to  place  the 
head  in  a  collar  attached  to  a  cross-bar  above  the  head,  suspended  from  the  ceiling, 


840  Diseases  of  Children    . 

by  a  compound  pulley  and  rope.  The  patient  now  grasps  the  rope  as  high  up  as 
possible,  and  pulls  up  hand  over  hand  until  the  toes  just  touch  the  floor.  While 
hanging  thus  she  takes  three  deep,  full,  slow  inspirations  and  expirations.  While 
she  is  hanging  thus  the  surgeon  corrects  the  rotation  by  pushing  the  ribs  with  one 
hand  while  he  steadies  the  pelvis  with  the  other. 

Another  good  thing  is  for  the  patient  to  have  a  belt  passing  around  the  pelvis, 
•with  a  handle  at  each  side.  Holding  these  in  the  hands,  she  straightens  the  arms 
out,  and  the  spinal  column  is  thus  stretched  and  straightened  much  in  the  same 
way  as  by  self-suspension. 

The  patient  stands  bent  forward  asif  playing  leap-frog,  her  hands  on  a  chair, 
while  the  surgeon,  with  one  hand  under  the  shoulder  on  the  convex  side  and  one 
hand  on  the  projecting  ribs,  corrects  the  rotation.  It  is  advisable  to  steady  the 
patient  with  the  knee  while  doing  this." 

Teschner  has  lately  (Annals  Surg.,  Aug., 1895)  advocated  the  system  of  exercises 
used  by  the  German  athlete  Attilla.  This  consists  of  a  long  series  of  the  usual 
light  dumb-bell  exercises  with  poising  of  the  body  in  various  positions.  These 
are  followed  by  swinging  and  raising  at  arms'  length  above  the  head  very  heavy 
dumb-bells  and  bars.  The  object  being  to  thoroughly  tire  out  the  weak  muscles, 
on  the  ground  that  in  this  way  only  can  they  be  fully  and  rapidly  developed. 

Rachilysis  and  other  very  forcible  methods  of  reducing  rotary  lateral  curvature 
have  not  found  thus  far  much  favor  in  this  countiy. 

Apparatus  for  Lateral  Curvature. — The  supports  used  in  the  United  States 
for  lateral  curvature  are  employed  to  retain  an  improved  position  and  to  relieve 
pain  and  weakness.  Muscular  development  is  at  the  same  time  encouraged  in 
■every  way,  the  idea  being  to  lay  aside  the  apparatus  as  soon  as  the  muscles  have 
been  made  strong  enough  to  retain  the  improved  position.  Some  cases  seen  late 
in  the  disease  cannot  be  improved  in  respect  to  deformity,  and  yet  feel  much  more 
•comfortable  if  properly  supported.  Others,  again,  from  cardiac  or  pulmonary  com- 
plications, cannot  take  the  exercises  required,  and  the  ultimate  results  are  better 
when  mechanical  treatment  is  carried  out.  In  order  that  the  appropriate  exercises 
may  be  given  all  supports  must  be  removable.  Probably  the  plaster-of-Paris  jacket 
applied  with  suspension  is  more  generally  used  than  any  other  method.  Sayre 
moulds  the  patient's  figure  with  his  hands  as  much  as  possible  after  the  jacket  is 
applied  and  before  it  hardens.  He  uses  the  jacket  as  an  adjuvant  and  only  in 
'those  cases  where  the  patient  is  not  able  to  retain  by  voluntary  effort  so  good  a 
position  of  the  body  as  can  be  obtained  by  partial  self-suspension  by  means  of  a 
pulley  and  head-swing.  Bradford  uses,  in  cases  which  are  markedly  resistant  and 
in  growing  patients  where  rigidity  is  not  complete,  permanent  plaster-of-Paris  jack- 
ets, exerting  a  correcting  pressure  upon  the  abnormally  prominent  ribs,  while  the 
jacket  is  still  soft,  from  behind  forward  and  from  before  backward,  by  means  of  a 
screw  force  extending  from  a  circular  steel  ring  which  is  placed  ai^ound  the  patient's 
trunk  temporarily   while  the  jacket  is  being  applied. 

Steele  recommends  a  raw-hide  jacket.  Phelps  uses  an  aluminium  corset  (Trans. 
Amer.  Orthop.  Assoc,  1893),  or  one  of  wood-shavings  (Waltuck  Method,  New 
England  Medical  Monthly,  February,  1892),  and  Vance  one  of  paper.  Roberts 
("Transactions  Ninth  International  Congress,"  vol.  iii.)  has  devised  a  wire  corset, 


Appendix  84 1 

designed  to  exert  a  continuous  elastic  pressure.  Shaffer  uses  a  light  steel  appa- 
ratus, adapted  to  exert  pressure  in  the  desired  direction,  at  the  same  time  allowing 
-some  antero-posterior  movements  of  the  trunk.  Exercises  are  systematically  used 
in  addition. 

DISEASES    OF    THE    BONES. 

Ununited  Fractures  (p.  645).— Ridlon,  in  cases  of  delayed  union  in  fractures 
of  the  leg  (New  York  Medical  Record,  January  31,  1891),  following  Thomas,  advo- 
cates the  use  of  the  latter's  caliper  splint,  but  so  modified  as  to  permit  of  no  motion 
at  the  ankle,  and  with  a  laced  leather  leg-sleeve  added. 

The  advantages  claimed  over  plaster-of- Paris  are  better  immobilization,  and  no 
constriction  at  the  seat  of  fracture.  The  apparatus  allows  the  patient  to  go  about 
during  treatment  and  permits  the  production  of  cedema  by  damming. 


DISEASES  OF  THE  JOINTS. 
Origin  (p.  660). — Northrup  has  given  some  instructive  records  of  autopsies 
bearing  on  this  point  (New  York  Medical  Journal,  February  21,  1891).  He 
found  that  the  pi-imary  seat  of  tubercular  infection  was  in  the  bronchial  lymph- 
nodes  in  a  great  majority  of  cases.  In  125  cases  examined,  34  had  too  extensive 
lesions  to  determine  which  was  primary  ;  20  had  the  oldest  lesion  in  the  respiratory 
tract;  42  had  cheesy  masses  in  bronchial  lymph  nodes  only,  more  recent  tubercules 
were  found  in  lungs  and  elsewhere.  In  9  all  the  tubercular  process  was  confined 
to  these  nodes  and  the  lungs.     In  13  it  was  limited  to  the  nodes  alone. 

Abscess  in  Joint  Disease  (p.  660). — The  treatment  of  tubercular  abscesses 
'has  always  been  a  matter  of  debate.  Townsend  (Trans.  Amer.  Orthop.  Assoc, 
iSgi)  has  found  that  nearly  fifty  per  cent,  of  a  large  number  of  cases  which  he  col- 
lected and  analyzed  were  by  repeated  aspirations  relieved  and  the  abscess  eventu- 
ally disappeared.  Some  surgeons  incise  and  drain  them  as  soon  as  fluctuation  is 
found,  whether  they  have  become  infected  or  not. 

In  a  paper  on  "  Operative  Interference  in  Abscess  of  Chronic  Tubercular  Disease 
of  the  Joints,"  read  before  the  New  York  Academy  of  Medicine,  in  October,  1S95, 
Shaffer  said  that  he  waited  until  there  were  severe  general  or  local  symptoms  due  to 
the  abscess  itself  before  he  incised  it.  So  long  as  we  knew  of  its  existence  by 
sight  and  touch  only,  we  were  justified  in  ignoring  it.  He  found  that  many 
of  them  disappeared,  and  few,  if  any,  gave  rise  to  trouble,  and  that  those  which 
opened  spontaneously  uniformly  did  well.  In  the  adult  and  adolescent,  an  invariably 
favorable  prognosis  could  be  given  if  the  non-operative  method  be  adopted  together 
with  efificient  mechanical  treatment,  whereas  the  prognosis  was  not  so  certainly  good 
if  the  abscess  were  operated  upon.  The  efficiency  of  the  mechanical  treatment 
was.  of  course,  very  important.  There  are  cases  in  which  mixed  infection  occurs 
and  in  which  there  may  be  symptoms  indicating  a  minor  degree  of  septicaemia. 
Even  here  Shaffer  advised  waiting  awhile  before  incising.  If  the  joint  is  properly 
protected,  the  urgent  symptoms  will  probably  subside.  If  they  persist,  a  free  in- 
cision must  be  made.     Ordinarily  the  abscess  should  be  allowed  to  open  spontane- 


842  Diseases  of  Children 

ously,  then  simple  external  dressings  are  applied  and  the  parts  kept  clean  with  per- 
oxide of  hydrogen  or  bichloride  of  mercury.  The  ultimate  recovery  of  the  joint 
is  better  under  the  non-operative  treatment  than  after  incision  of  the  abscess. 

Dane  has  endeavored  to  find  a  method  of  discovering  whether  these  cold  ab- 
scesses have  become  infected  or  not,  and  has  published  his  work  in  a  recent  number 
of  the  Aviei'ican  Journal  of  the  Medical  Sciences.      His  conclusions  are  : 

1.  Most  cases  of  tuberculosis  of  the  bones  and  joints  do  not  decrease  the 
number  of  the  red  corpuscles  in  the  blood. 

2.  They  do,  however,  affect  the  percentage  of  hsemoglobin,  giving  rise,  in  fact, 
to  a  mild  degree  of  chlorosis. 

3.  The  leucocyte  count  seems  to  have  no  special  relation  to  the  tempera- 
ture. 

4.  High  counts,  especially  in  hip  disease,  point  to  the  probability  that  there  is 
or  shortly  will  be  abscess  formation,  but  low  counts  do  not  preclude  the  presence 
of  pus,  especially  in  long-standing  cases. 

5.  Where  an  abscess  is  found  in  the  face  of  a  low  leucocyte  count,  the  pus 
from  it  is  sterile,  that  is,  does  not  contain  pyogenic  organisms:  it  does  often  contain 
tubercle  bacilli.     The  case  is  generally  one  of  long  standing. 

6.  In  the  presence  of  an  abscess  a  low  leucocyte  count  indicates  the  absence 
and  a  high  count  the  presence,  of  a  secondary  infection  with  pyogenic  organisms. 

7.  Cases  where  at  the  primary  operation  the  pus  has  proved  sterile,  generally 
show  an  increase  in  the  leucocyte  count,  and  especially  in  the  differential  count, 
where  the  wound  becomes  infected  with  the  pyogenic  organisms. 

8.  High  total  leucocyte  counts  do  not  always  affect  the  differential  count. 
Dane  in  these  investigations  used  the  Thoma-Zeiss  apparatus.     The  red  pipette 

was  diluted  1-200  with  "  Toison's  solution,"  and  the  white  in  a  separate  pipette 
i-ioo  with  yfo  acetic-acid  solution  and  a  little  methylene  violet.  The  dry  slides  were 
hardened  in  benzine,  and  stained  with  Ehrlich's  triple  stain. 

Case  I.  — Boy  six  years  old.  Hip  disease,  one  and  a  half  years'  duration.  De- 
veloped an  abscess  about  four  months  previously.  Entered  with  large  fluctuat- 
ing tumor  both  in  front  and  behind  joint.  Operation  showed  §  v  greenish  puri- 
form  material.  Head  of  bone  nearly  separated,  and  rim  of  acetabulum  much 
roughened. 

Blood  count  : 

Erythrocytes 6,096,000 

Hsemoglobin 75^ 

Leucocytes . . .  : 6,756 

Lymphocytes.  . .  .■ 28^ 

Large  mononuclear  and  transitional  forms \i% 

Polynuclear  neutrophiles 58^ 

Eosinophiles 2% 

Pus  proved  sterile  from  pyogenic  organisms. 

Case  II. — Girl  three  years  old.  Hip  disease,  seven  months'  duration.  Abscess 
for  two  months.  Large  fluctuating  swelling  on  anterior  aspect  of  thigh  over  great 
trochanter.  Operation  gave  §  vi  pus,  and  showed  a  sinus  leading  into  the  joint, 
which  was  not  much  disintegrated. 


Appendix  843 


Blood  count : 

Erythrocytes 3, 744,000 

Hjemoglobin 65J» 

Leucocytes 41, 369 

Lymphocytes 14^ 

Large  mononuclear  and  transitional  forms   5^iJ 

Polynuclear  neutrophiles 817^ 

Eosinophiles o'fc 

Pus  showed  the  presence  of  Staphylococcus  pyogenes  aureus  and  Staphylococcus 
pyogenes  albus. 

Mechanical  treatment.  Shoulder  (p.  664). — To  apply  extension  at  the 
shoulder  Shaffer  uses  an  axillary  crutch,  to  which  is  attached  an  extension-bar  run- 
ning down  the  inner  aspect  of  the  arm,  and  terminating  in  a  band  which  half 
encircles  the  arm.  Adhesive  straps  are  applied  and  fastened  to  this  band,  and  the 
extension-bar  lengthened  as  required. 

Townsend  (Trans.  Amer.  Orthopedic  Assoc,  vol.  vii.)  claims  that  the  usual 
termination  of  this  disease  under  mechanical  treatment  is  ankylosis  more  or  less  com- 
plete, as  a  rule  limiting  the  ability  to  raise  the  arm  from  the  side  to  about  one-third 
or  one-fourth  the  normal  amount.  This  loss  of  function  is  a  serious  matter  in 
many  cases,  and  only  such  work  can  be  done  in  severe  cases  as  requires  but  little 
force,  and  such  as  can  be  supplied  by  the  forearm  alone.  When  the  patients  can 
get  the  hand  to  the  head  to  feed  and  dress  themselves  the  condition  is  not  so  seri- 
ous. Townsend  claims  that  after  partial  or  complete  excisions  much  more  freedom 
of  motion  can  be  obtained  in  most  cases.  Rejecting  the  statistics  of  pre-antiseptic 
days  the  operation  does  not  appear  to  be  dangerous.  The  joint  is  easy  of  approach, 
and  in  a  large  majority  of  instances  the  disease  is  located  in  the  head  of  the 
humerus,  and  can  thus  be  entirely  removed.  By  partial  operations  and  the  sub- 
periosteal method  the  growth  of  the  limb  should  not  be  much  affected.  In  regard 
to  mechanical  treatment  Townsend  says  that  in  no  case  that  he  had  treated  was 
this  method  given  a  fair  trial,  but  that  from  careful  reading  and  the  examination 
of  some  patients  supposed  to  have  been  subjected  to  careful  mechanical  treatment 
he  had  been  led  to  the  belief  stated  above. 

Mondan  and  Audry  (Revue  de  Chirurgie,  1S92)  found  as  the  results  of  thirty- 
two  excisions,  all  done  on  patients  near  adult  life,  that  the  starting  point  of  the 
disease  was  in  twenty-nine  cases  in  the  bone,  in  one  doubtful,  and  in  three  it  was 
clearly  synovial.  In  twenty-three  of  these  cases  the  disease  originated  in  the 
humerus,  in  four  in  both  the  scapula  and  the  humerus,  and  in  one  in  the  scapula. 

Elbow  (p.  664). — To  immobilize  the  elbow  Myers  uses  a  splint  formed  by 
wires  that  follow  the  upper  and  lower  borders  of  the  hand  and  forearm,  the  an- 
terior and  posterior  borders  of  the  arm,  and  then  descend  on  the  side  of  the  body 
to  the  waist-line  ;  a  laced  sleeve  holds  the  hand  and  forearm,  and  another  the 
arm.  Thoracic  and  abdominal  straps  hold  the  splint  firmly  against  the  body. 
This  controls  the  short  limbs  of  children  well. 

Wrist-joint.  Excision  (p.  665). — Mynter  (Trans.  Amer.  Orthpedic  Assoc, 
vol.  vii.)  considers  the  results  of  iodoform  injections  excellent,  and  therefore  thinks 
early  operation  distinctly  contraindicated.     Excision  should  only  be  resorted  to  in 


.844 


Diseases  of  Children 


old  and  neglected  cases,  and  in  these  it  is  impossible  to  remove  by  the  usual  longi- 
tudinal incisions  of  Oilier  and  Lister  the  fatty,  degenerated,  softened,  and  carious 
bones  except  in  piecemeal,  leaving  a  large  amount  of  the  tuberculous  bony  tissue 
and  a  still  larger  amount  of  the  tuberculous  synovial  tissue  in  the  wound.  I'rc- 
tracted  suppuration  and  tuberculous  relapses  necessitating  repeated  operations,  and 
possibly  amputation,  may  follow.  In  order  to  gain  free  access  to  the  diseased  focus, 
Myriter,  following  the  suggestion  of  Studsgaard,  advocates  a  complete  splitting  of 
the  hand  from  before  backward,  but  he  makes  his  longitudinal  incision  between 
the  second  and  third  metacarpal  bones,  then  entering  between  trapezoid  and  os 
magnum,  and  between  scaphoid  and  semilunar  bones,  as  the  hand  is  more  evenly 
divided  by  this  incision  than  by  the  one  recommended  by  Studsgaard,  which  passes 
between  the  third  and  fourth  metacarpal  bones,  and  then  opens  up  the  joints  be- 
tween OS  magnum  and  unciform  bone,  and  between  semilunar  and  cuneiform 
bones.  Mynter  operated  in  March,  1894,  by  this  method.  He  made  the  dorsal 
incision  reach  up  to  the  radius,  but  found  it  unnecessary  on  the  palmar  side  to  ex- 
tend the  incision  farther  than  the  base  of  the  thenar  of  the  thumb.  The  annular 
volar  ligament  was,  therefore,  not  severed.  By  careful 
dissection  from  the  dorsal  side,  and  forcible  separation, 
he  found  it  easy  to  avoid  wounding  the  dorsal  tendons 
and  the  large  palmar  tendinous  bursa.  The  whole  car- 
pus could  now  be  widely  opened,  and  it  was  extremely 
easy  with  scissors  to  extirpate  the  two  halves  of  the 
carpus,  and  with  a  fine  saw  to  remove  the  surfaces  of 
the  radius,  ulna,  and  the  metacarpal  bones.  The  cavity 
was  packed  with  iodoform  gauze.  The  wound  healed 
promptly  and  the  result,  eight  weeks  after  the  operation, 
was  extremely  gratifying.  The  patient  can  actively  ex- 
tend and  flex  the  wrist  and  move  the  fingers,  but  there  is 
still  some  looseness  of  the  wrist-joint,  though  it  is 
steadily  getting  firmer.  Mynter  considers  this  opera- 
tion far  superior  to  OUier's  and  Lister's  longitudinal,  or 
the  old  transverse  incisions,  as  by  these  last  methods 
we  necessarily  get  adhesion  of  the  tendons  to  the  cica- 
trix. 

Hip-joint. — In  the  United  States  all  surgeons  agree 
that  during  the  acute  symptoms  of  hip-joint  disease  the 
limb  must  be  immobilized  as  perfectly  as  possible. 
Traction  is  applied  during  this  time  to  overcome  the 
reflex  muscular  spasm  almost  as  invariably.  After  the 
pain  and  deformity  are  overcome,  the  practice  varies  somewhat.  Some  few  rely 
on  immobilization  alone,  using  a  plaster-of- Paris,  spica,  or  a  Thomas  hip-splint,  or 
similar  device.  The  large  majority,  however,  combine  traction  with  immobiliza 
lion,  more  or  less  complete,  until  all  reflex  muscular  spasm  has  disappeared.  After 
this  the  joint  is  still  protected  from  pressure  for  mouths  to  avoid  a  relapse.  In 
the  United  States,  therefore,  the  long  traction  hip-splint  (Davis-Taylor)  (Fig.  220) 
is  used  almost  exclusively  until  the  convalescent  stage.     Then  Sayre  sometimes 


Fig.  220.— The  Davis-Taylor 
Long  Traction  Hip-splint. 


Appendix 


845 


uses  his  short  traction  splint,  or,  like  Shaffer,  Taylor,  and  Bradford,  a  perineal 
crutch  permitting  motion  at  the  knee  and  affordfng  a  modified  protection  from  the 
traumatism  of  percussion. 

Where  the  child  is  large  or  very  heavy  the  use  of  axillary  crutches,  in  addition  to 
the  hip-splint,  will  be  advantageous  in  some  cases.  As  much  traction  is  applied  by 
the  hip-splint  as  can  be  borne  with  comfort  by  the 
patient.  Where  sliglit  traction  causes  pain,  this  is 
due  to  the  tension  of  an  abscess  under  the  fascia  lata. 

Knee-joint  (p.  675). — Traction  is  successfully 
■used  also  at  the  knee  to  reduce  the  deformity  and 
relieve  the  i^jain.  It  must  be  applied  in  the  direc- 
tion of  the  deformity,  and  continued  as  long  as 
there  is  any  reflex  muscular  spasm.  Sayre's  ex- 
tension knee-brace  is,  perhaps,  the  one  best  known. 
Where  there  is  deformity  New  York  surgeons  em- 
ploy traction  for  a  longer  time  than  is  recommended 
in  England  (p.  67S),  before  resorting  to  forcible 
manipulations,  as  many  cases  which  will  not  yield 
in  a  few  weeks  will  do  so  in  a  few  months,  and 
all  traumatism  will  thus  be  avoided.  Many  sur- 
geons who  apply  traction  at  the  hip-joint,  how- 
ever, are  content  to  protect  the  knee-joint  from 
motion  and  percussion. 

Shaffer  recommends  a  splint  for  cases  of  sub- 
luxation (p.  67S)  unless  there  is  ankylosis,  which 
■exerts  forward  pressure  on  the  head  of  the  tibia, 
and  longitudinal  traction  in  the  line  of  the  de- 
formity (Archives  of  Clinical  Surgery,  June,  1877). 

Goldthwaite  (Bost.  M.  &  S.  Jour.,  Sept.  7, 
1893)  describes  a  very  admirable  modification  of 
Bradford's  apparatus  for  correcting  posterior  sub- 
luxation of  the  head  of  the  tibia  in  cases  where 
there  is  no  bony  ankylosis.  Under  anaesthesia 
the  adhesions  are  broken  up  carefully  by  one  or  steel  loops  "  e."  The  coumer-press- 
,.      ,.  r     ,       .  1  •  ure  is  exerted  by  the  straps  "f " 

more   applications  of  the  lever,  and  a  protective         j  u     ^    t-i,    1      ■  .i,  c  .1 

'  "^  _  ^  and     g.       The  leg  IS  then  carefully 

splint  worn  afterwards  until  the  disease  is  cured  straightened  by  the  lever  arm  "  h." 
(see  Fig.  221). 

Amputation  (p.  680)  for  tubercular  disease  of  the  knee-joint,  without  other 
lesions,  is  very  rarely  done  here.  Gibney  has  had  but  one  case  requiring  it  in  the 
last  five  years  at  the  Hospital  for  the  Relief  of  the  Ruptured  and  Crippled  ;  at  the 
New  York  Orthopedic  Hospital  this  operation  has  not  been  advised  or  done  in 
that  time. 

HIP   DISEASE. 

Muscular  Spasm  (p.  693). — Involuntary  reflex  muscular  spasm  is  generally  con- 
sidered in  America  the  most  constant  symptom  of  hip  disease.  It  appears  first  and 
disappears  last,  and  is  the  safest  guide  as  to  the  presence  or  absence  of  the  disease. 


Fig.  221.  — Bradford-Gold  thwaite 
Brace  for  Correcting  Deformity 
at  the  Knee. 

To  apply  the  brace  :  The  head  of 
the  tibia  is  forced  forward  as  far 
as  possible  by  the  screw  "  b  "  work- 
ing in  the  arch  "a,"  which  raises 
the  cross  bar  "  c  "  to  which  the  pos- 
terior band  "d  "  is  attached  by  the 


846  Diseases  of  Children 

The  ivriter  during  his  observations  of  hip-joint  disease  under  the  tuberculin 
treatment  at  St.  Luke's  Hospital,  made  daily  careful  examinations,  and  came  to 
the  conclusion  that  the  reflex  muscular  spasm  was  the  first  symptom  affected  by  the 
injections.  In  the  cases  with  more  marked  reaction  the  symptoms,  although  last- 
ing but  a  few  days,  exactly  resembled  the  usual  exacerbations  of  the  disease,  with 
increase  of  reflex  spasm,  less  motion,  or  even  appearance  of  deformity,  increase  of 
pain  and  sensitiveness,  and  recurrence  of  night  cries.  In  less  marked  reactions 
several  times  the  reflex  muscular  spasm  became  more  alert,  though  there  was  no 
rise  of  temperature,  nor  appreciable  increase  of  joint-sensitiveness  or  decrease  in 
motion.  One  case  he  had  examined  repeatedly  six  weeks  after  all  pain,  deformity, 
and  limp  had  disappeared,  and  the  reflex  spasm  was  always  detected. 

Deformity  (p.  705). — Exacerbations  sometimes  follow  rapid  reduction  of  the 
deformity  under  anaesthesia.  When  traction  is  used  for  this  purpose  it  must  be 
applied  in  the  line  of  deformity,  whatever  the  position  of  the  limb  may  be. 

Phelps  ("Transactions  New  York  State  Medical  Society,"  February,  1889) 
strongly  recommends  that  traction  be  made  in  the  line  of  the  axis  of  the  neck  of  the 
femur,  not  in  the  axis  of  the  shaft. 

Phelps  (p.  693)  explains  the  deformities  of  the  different  stages  of  hip-joint 
disease  as  follows  :  The  first  stage  is  produced  by  voluntary  effort  on  the  part  of 
the  patient,  aided  by  spasm  of  the  muscles,  in  order  to  relieve  the  tension  of  the- 
Y-ligament  and  capsule  of  the  joint ;  hence  abduction,  outward  rotation,  and  flexion. 
Muscular  spasm  and  a  voluntary  effort  exaggerate  the  deformity  of  the  first,  pro- 
ducing that  of  the  second  stage.  When  flexion  takes  place  beyond  thirty  degrees, 
and  often  with  less  flexion,  the  limb  rapidly  assumes  the  position  of  the  third  stage 
(with  an  occasional  exception),  adduction,  inward  rotation,  and  flexion,  for  the 
following  reasons  :  when  the  limb  is  thus  flexed  the  glutei  muscles  and  the  tensor 
vaginae  femoris  become  inward  rotators.  The  glutei  cease  to  be  abductors,  and  the 
external  rotators  are  no  longer  rotators  but  abductors,  with  the  exception  of  the 
quadratus  femoris  and  obturator  externus.  The  adductors,  now  being  no  longer 
antagonized  by  the  great  glutei  muscles,  cause  the  adduction. 

The  erratic  deformities  he  accounted  for  by  destruction  of  bone  changing  or 
destroying  leverage,  buiTowing  of  pus,  dislocation,  perforation  of  acetabulum,  and 
locking  of  the  head  of  the  femur  in  the  pelvis  ;  possibly  by  the  location  of  the 
lesion,  adhesions,  and  irritation  of  special  nerve-plates  supplying  the  joint.  The 
fluid  tension  hypothesis  he  thought  erroneous,  because  many  cases  were  unattended 
by  effusion,  and  many  cases  of  all  the  deformities  seen  in  hip-joint  disease  were 
extra-capsular. 

Results  (p.  701). — Sayre  {A^ew  York  Medical  Journal,  April  30,  1892)  shows 
that  in  407  cases  treated  by  him  without  excision,  the  ultimate  result  was  : 

Cure,  motion  perfect     71 

"           "      good   142 

"           "      limited 83 

' '      ankylosis 5 

Unknown 78 

Under  treatment,  14  ;  abandoned,  3  ;  discharged,  2.     Total  deaths,  9. 


Appendix 


847 


As  the  Thomas  hip-splint  (p.  705)  docs  not  afford  traction  it  is  not  commonly 
used  in  the  United  Stales. 

Excision  of  the  Hip  (p.  706). — In  general  there  is  a  strong  conservative  feel- 
ing at  present  among  American  orthopedic  surgeons  on  the  question  of  hip-joint 
excision.  It  is  considered  a  last  resort,  to  be  applied  only  in  exceptional  cases 
where  conservative  treatment  cannot  be  carried  out,  or  as  a  means  of  saving  life. 
Bradford  and  Lovett  express  the  general  feeling  when  they  say,  "  It  must  be  borne 
in  mind  that  the  ultimate  results  after  early  excision  are  much  more  favorable  than 
after  late  excision.  Where  a  late  excision  is  done  the  surgeon  will  always  regret 
that  the  operation  had  not  been  done  before.  The  results  of  careful  conservative 
treatment,  if  carried  out  for  a  long  time,  are  superior  to  those  after  excisions  in  a 
majority  of  cases,  and  where  conservative  treatment  is  practicable  it  should  be  pre- 
ferred. In  large  hospitals  or  among  the  poor  and  unintelligent  class  conservative 
treatment  is  sometimes  impracticable,  and  in  such  cases  excision  is  resorted  to  earlier 
than  would  otherwise  be  justifiable,  and  the  results  gained  are  more  satisfactory 
than  when  the  operation  is  deferred." 

SPINAL   DISEASE.  • 

Symptoms  (p.  71S). — Myers  has  seen  in  several  cases  of  high  cervical  disease 
severe  attacks  of  dyspnoea  and  heart-failure,  probably  due  to  pressure  on  the  cord, 
two  of  them  ending  fatally. 

Treatment  (p.  720). — Recumbency  is  strongly  advocated 
by  Steele  {Medical  Fortnightly,  February  i,  189I),  who 
straps  his  patient  to  a  canvas-covered  iron  frame  and  ap- 
plies head  traction  when  the  disease  is  in  the  cervical  and 
upper  dorsal  regions  (see  also  Bradford  and  Lovett,  "  Or- 
thopaedic Surgery,"  p.  54,  and  Schapps,  Medical  Record,  Sep- 
tember 9,  1893). 

Taylor's  spinal-assistant  brace  (Fig.  222)  is  also  largely 
used  in  America  (p.  721)  for  disease  in  all  regions.  When 
the  disease  is  above  the  seventh  dorsal  vertebra  a  chin-cup 
with  occipital  uprights  is  attached  to  the  brace  by  means  of 
a  ball-and-socket  joint,  placed  as  near  the  occipito-atloid  joint 
as  possible,  and  the  head  can  then  be  held  in  any  position 
■desired. 

Taylor  (p.   721)    {Medical  News,  No.  1,158,  p.  317)  has 

devised  a  safe,  efficient,  and  easy  method  of  applying  a  plaster- 

■of- Paris   jacket.      The    patient   sits  upon   a    bicycle  saddle 

with   feet  resting  on   and   fastened  to   rigid   stirrups.     The 

hands  grasp  handles  above  and  a  little  behind  the  head,  so 

hyperexlending    the    spine.      Head  suspension    can    also  be 

AA   A    -c  T      ^v.-  -1  r    •  -1  Fig.  222.— Taylor's  Spin- 

added   if  necessary.      In  this  way,   without   fatigue,  without    al  Brace  with  Chin-cup. 

motion,  and    with  rapidity  a  jacket  can  be  applied  to  either 

a  child  or  a  heavy  adult,  and  the  support  can  be  carried  liigher  up  in  front  than  is 

readily  done  bv  the  other  methods. 

Lloyd   (p.  725)  {Annals  of  Surgery,  October,  1892)  has  tabulated  all  published 


848  Diseases  of  CJiildren 

cases  of  laminectomy  in  Pott's  disease  up  to  September,  1892,  as  well  as  several  not 
previously  reported.  He  concludes  that  the  operation  is  definitely  indicated  in  a 
certain  limited  class  of  cases. 

Gibney  (p.  725)  {Journal  of  Mental  and  Nervous  Diseases,  April,  1878),  Taylor 
and  Lovett  (New  York  Medical  Record,  June  iq,  1886),  Myers  ("  Transactions 
American  Orthopedic  Association,"  iSgo),  and  Iluddleston  {American  Journal  of 
Medical  Sciences,  August,  1894)  have  presented  statistics  on  a  large  number  of  these 
cases,  showing  the  frequency  of  recovery  from  the  paralysis  without  operation. 

CLUB-FOOT. 

Shaffer  (p.  729)  (New  York  Medical  Record,  May  23,  1885)  described  a  condi- 
tion of  modified  flexion  at  the  ankle  and  a  contracted  state  of  the  plantar  tissues 
which  he  called  non-deforming  club-foot.  The  symptoms  were  awkward  gait  asso- 
ciated with  painful  callosities  at  various  parts  of  the  foot  ;  or  in  more  severe  cases. 
actual  di>ability,  pain  in  various  parts  of  the  foot,  ankle,  and  leg,  and  even  reflected 
to  the  lumbar  region  ;  also  tender  and  inflamed  articular  surfaces,  especially  at  the 
junction  of  the  first  metatarsal  bone  with  its  phalanx. 

Wilson  (p.  732)  ("  Transactions  of  the  American  Orthopedic  Association,  1892  ") 
advocates  "the  complete  reduction  of  the  deformity  by  the  end  of  the  first  month 
of  life,  by  simpler  means  if  possible,  by  tenotomy  otherwise.  The  muscular  power 
of  the  foot  should  be  developed  as  much  as  possible  afterward."  Most  surgeons 
would  be  willing  to  wait  longer  before  resorting  to  operation. 

It  is  but  just  to  say  that'  the  surgeon  meets  a  large  class  of  cases  which  have 
been  neglected  for  two  or  three  years  or  more.  These  cannot  be  corrected  by  the 
simpler  forms  of  splints,  yet  can  be  saved  from  operative  treatment  by  the  use  of 
suitable  stretching  splints  applied  by  a  surgeon  who  knows  how  to  use  them. 

The  importance  of  maintaining  the  corrected  position  cannot  be  overestimated. 
Many  of  these  deformities  will  surely  and  slowly  recur,  whether  they  have  been 
cured  by  operation  or  without  it,  unless  exercises,  massage,  and  attention  to  the 
manner  of  walking  are  kept  up  for  a  year  or  so. 

Phelps  (p.  736)  recommends  the  following  order  of  operation,  that  one  may  fol- 
low the  other  at  once  if  required  :  i,  strong  manipulation  ;  2,  subcutaneous  tenot- 
omy ;  3,  open  incision  ;  4,  linear  osteotomy  of  the  neck  of  the  astragalus  ;  5,  V- 
shaped  piece  removed  from  body  of  os  calcis  ;  6,  removal  of  cuboid  and  scaphoid  ; 
7,  Pirogoff's  amputation.  Exceptionally  the  order  may  be  changed,  so  that  after 
4,  excision  of  the  astragalus  may  be  performed. 

Bradford  ("  Transactions  of  the  American  Orthopedic  Association,  1892  ")  found 
that  "when  the  foot  could  not  be  brought  straight  after  section  of  all  the  soft  parts 
on  the  inner  side  of  the  foot,  the  resistance  was  generally  located  in  the  neck  of  the 
OS  calcis,  and  he  advocated  in  these  cases  the  excision  of  a  wedge  from  this  bone 
just  posterior  to  the  line  of  cartilage  "  He  said  :  In  a  normal  foot  a  line  drawn 
through  the  middle  of  the  sole  is  a  straight  one,  but  in  case  of  club-foot  after  the 
removal  of  the  astragalus  the  median  line  in  front  of  the  medio-tarsal  articulation 
formed  an  angle  with  the  median  line  posterior  to  the  articulation.  This  was  due 
to  the  obliquity  of  the  anterior  facet  of  the  os  calcis.  See  also  Phelps's  article  on 
this  svib]eci  {University  Medical  Magazine,  March,  1892). 


Appendix 


849 


Parrish  (p.  736)  {Medical  Journal,  October  8,  1892)  describes  a  method  he  has 
devised  of  suturing  live  tendons  to  those  paralyzed,  and  so  regaining  lost  function. 
He  has  sutured  the  healthy  extensor  pollicis  tendon  to  the  paralyzed  tibialis-anticus 
tendon  to  remedy  a  case  of  valgus. 

Whitman  (p.  740)  (  New  York  Medical  Jotirnal,  November  9  and  16,  1895)  has 
devised  an  arched  steel  sole  for  the  treatment  of  flat-foot  which  acts  as  a  lever  to  throw 
the  inner  edge  of  the  foot  up  in  walking  and  yet  is  so  short  that  it  does  not  restrict  nor- 
mal muscular  action.  If  the  foot  can  be  replaced  in  proper  position,  if  its  movements 
are  free  and  not  limited  by  muscular  spasm  or  inflammatory  adhesions  the  sole  can 
be  applied  at  once,  and  with  a  proper  shoe,  an  avoidance  of  faulty  positions,  and  exer- 
cises for  strengthening  the  weakened  muscles  the  patient  will  be  at  once  relieved. 


Fig.  223. — Whitman's  Flat-foot  Support. 


Astragalo-scaphoid  joint. 
Ball  of  great  toe. 


B.  Calcaneo-cuboid  joint. 
D.  Middle  of  heel. 


If,  however,  the  reduction  by  manipulation  is  impossible,  the  foot  should  be  forcibly 
moved,  under  anaesthesia,  in  all  directions  to  break  up  adhesions,  and  then  forced 
into  a  position  of  extreme  adduction  or  equino-varus  and  retained  there  in  a  well- 
padded  plaster  bandage.  Although  great  force  is  sometimes  used,  the  after  symp- 
toms are  usually  slight,  and  the  patient,  if  he  desires,  may  walk  about  on  the  plaster 
bandage  the  following  day.  In  from  one  to  three  weeks  the  bandages  are  removed 
and  active  treatment  begun.  The  foot  is  now,  though  in  good  position,  stiff,  and 
all  its  movements  are  restricted  and  painful.  It  is,  therefore,  immersed  in  hot 
water,  massaged,  and  slowly  forced  into  a  position  of  adduction.  Voluntary  exer- 
cises are  then  executed  for  twenty  minutes.  These  are  repeated  several  times  a 
day  and  the  surgeon  once  daily  forces  the  foot  into  the  hyper-corrected  position. 
The  sole  is  made  of  thin  steel  molded  while  hot  on  an  iron  cast  of  the  foot  in  its 
corrected  position,  and  is  then  tempered  so  that  it  is  unyielding  under  the  weight 
of  the  body.  Fig.  223  shows  the  form  and  application  of  these  supports.  Whit- 
man calls  attention  particularly  to  the  following  points  : 


850 


Diseases  of  Children 


r.  That  there  should  be  an  accurate  adjustment  of  the  support  to  the  cast  of  the 
corrected  foot  :  {\i  is  never  applied  to  a  stif?  and  deformed  foot). 

2.  Lateral  support  is  afforded  as  well  as  support  from  beneath,  and  thus  is  pre- 
vented the  dislocation  of  the  astragalus,  ihe  abduction  and  valgus,  the  important 
elements  of  so-called  flat-foot. 

3.  Leverage.  The  weak  foot,  properly  balanced  in  a  Waukenphast  shoe,  and  used 
properly,  will  press  the  outer  arm  against  the  sole,  and  thus  tighten  the  inner 
flange  of  the  brace  against  the  astragalo-scaphoid  junction,  where  the  prelimi- 
nary bulging,  the  first  sign  of  flat-foot,  appears. 

4.  Non-interference  with  the  functions  of  the  foot  The  component  parts  being 
held  in  proper  relation  to  one  another,  the  foot  may  again  become  strong  by 
proper  exercise,  the  proper  walk,  and  proper  attitude,  and  the  brace  may  then  be 
discarded. 

Shaffer  has  found  that  in  very  many  cases  a  shortening  of  the  tendo  Achillis 
precedes  the  appearance  of  flat-foot.  Flexion  being  prevented  at  the  ankle-joint 
occurs  at  the  medio-tarsal  joint.  He  therefore  advocates  restoring  to  this  tendon 
its  normal  length,  as  a  necessary  part  of  the  treatment. 

A  very  early  sign  of  commencing  flat-foot  is  a  rotation  of 
the  whole  foot  on  an  antero-posterior  axis,  therefore  lateral 
support  to  the  astragalus  is  important.  As,  after  the  bones 
have  been  restored  to  the  normal  positions,  a  cure  of  the  de- 
formity must  be  maintained  by  increased  muscular  power,  and 
as  direct  pressure  weakens  the  muscle  pressed  upon,  all  steel 
soles  and  springs  are  theoretically  objectionable. 

The  treatment  adopted  at  the  Orthopedic  Hospital  to  meet 
these  indications  is  correction   of  the  shortening  of  the  tendo 
Achillis   by   forcible  intermittent  stretching,    or    tenotomy   if 
necessary  ;  correction  of  the  rotation  of  the  whole  foot  on  the 
antero-posterior  axis   by  manual  or  mechanical  force  ;  correc- 
tion of  the  abduction  of  the  toes  in  the  same  way,  and  main- 
tenance of  the  corrected  position  by  the  use  of    steel  ankle 
supports,  riveted  to  the  shoes,  allowing  free  flexion  and  ex- 
tension at  the  ankle-joint  and  so   encouraging  muscular  de- 
velopment, yet  affording  firm  lateral  support  to  the  tarsus  and 
Fig.     224.  —  Shaffer's   also  holding  the  inner  side  of  the  foot  a  little  higher  than  the 
Flat-foot  Support.       outer  side,  which,  therefore,  is  made  to  carry  most  of  the  weight 
I.  Astragalo-scaphoid   in  walking.      (See   Fig.  224.) 
pad.    2,  Inner  side  of         Torticollis  (p.  741).— The  Taylor  spinal-assistant  brace, 
sole  piece  raised  high-       .  ,     .         ,  .        .  ,         ....  .    ,  .  ,,         .      , 

er  than  outer  side,  3.       '"'^*  '^^  chm-piece  and  occipital   uprights,  is  well   suited  to 
these  cases.      It   can  be  readily  adjusted  to  any  position  of 
the  head,  and  as  easily  re-adjusted  to  an  improved  position. 

Keen  (Annals  Surgery,  October,  1891).  Gardner  {AnsiraXxd^n  Medical  Journal, 
February,  1893),  Powers  (New  York  Medical  Jow-nal,  i8g2,  p.  253),  and  others 
have  resected  the  posterior  branches  of  the  upper  cervical  nerves  with  success  after 
resection  of  the  spinal  accessory  had  failed. 

Genu  Recurvatum  (p.  750). — Myers,  in  examining  a  considerable  number  of 


Appendix  851 

cases  of  genu  recurvatum,  found  that  the  patella;  generally  develop  later  on,  though 
they  may  not  be  found  at  birth. 

Arrest  of  Development  (746). — Hasse  and  Dehner  (Arch.  f.  Anat.  u.  Physiol. 
Abtheil.,  1893)  have  found  that  in  the  majority  of  cases  the  lower  limbs  are  of  un- 
equal length,  that  asymmetry  is  the  rule  and  not  the  exception. 

Club-hand  (p.  747)- — R.  H.  Sayre  (New  York  Medical  Journal,  November  4, 
1893)  operated  upon  an  aggravated  case  in  which  the  radius  and  thumb  were 
absent,  as  well  as  the  first  metacarpal  bone  and  a  certain  number  of  the  carpal 
bones.  The  marked  curve  in  the  ulna  was  first  corrected  by  osteotomy.  After 
union  in  a  straight  line  was  secured,  and  after  several  weeks  of  stretching  the  con- 
tracted tissues  had  failed,  the  styloid  process  of  the  ulna  was  cut  off,  the  os  magnum 
and  unciform  removed,  and  the  end  of  the  ulna  put  into  the  gap  in  the  carpus  thus 
formed.  The  hand  is  now  approximately  in  line  with  the  forearm.  There  is  free 
motion  at  the  wrist,  and  the  ability  to  grasp  objects  is  greater  than  it  was  before 
the  operation,  though  extension  of  the  hand  is  poor. 

Congenital  Dislocation  of  the  Hip  (p.  751).  — Gibney  (Annals  Surgery, 
December,  1894)  says  that  the  results  he  has  obtained  in  his  cases  of  congenital 
dislocation  of  the  hip  from  HofTa's  operation  have  been  far  from  satisfactory.  He 
reports  on  six  cases.  He  attributed  his  ill  success  to  some  fault  of  technique, 
since  suppuration  followed  the  operation  in  the  majority  of  cases.  The  age  also 
of  his  patients  was  too  far  advanced  in  most  of  the  cases. 

Bradford  (Annals  Surgery,  xx.,  No.  2,  p.  129)  found  that  contraction  of  the 
anterior  fibres  of  the  capsule  may  sometimes  prevent  reduction. 

Paci  (Arch,  di  Ortop.,  Ann.  ix.,  No.  6,  and  Ann.  x.,  No.  i)  reports  on  fifteen 
cases  treated  by  his  method,  and  the  results  are  almost  perfect  a  year  or  more  after 
operation.  Mis  method  is  to  forcibly  manipulate  the  limb,  as  if  to  reduce  a 
traumatic  dislocation — that  is,  the  limb  is  first  forcibly  flexed  as  far  as  possible, 
then  abducted,  then  rotated  outward,  then  extended.  Afterwards  the  thigh  is  held 
completely  extended  and  immobilized,  and  traction  applied.  If  the  shortening  is 
not  completely  overcome  at  the  first  operation,  a  subsequent  one  will  probably 
accomplish  the  reduction.  In  about  two  months  the  plaster-of-Paris  splint  is 
removed  and  an  extension  apparatus  applied.  Four  months  after  the  operation 
the  patient  is  allowed  to  get  up  and  walk  with  crutches.  At  night  the  extension 
is  reapplied.  The  limb  is  massaged  twice  daily,  and  once  a  day  receives  electrical 
treatment. 

Schede's  recently  recorded  cures  of  this  condition  by  conservative  treatment 
seem  to  indicate  that  a  persistent  attempt  should  be  made  to  cure  without  resort- 
ing to  the  open  operations  of  Hoffa  and  Lorenz,  if  this  is  practicable.  The  results 
from  operation  should  improve  with  improved  technique  and  more  careful  after- 
treatment.  Myers  (Annals  Surgery,  December,  1894)  found  the  mortality  in  one 
hundred  r;nd  seventy-three  recorded  cases  three  and  three-tenths  per  cent. 


852  Diseases  of  Children 


MILK. 

A  superstitious  belief  in  the  superior  virtues  of  the  milk  of  "one  cow"  is  still 
common  among  the  public,  and  it  is  often  looked  upon  as  a  most  important  matter 
to  secure  this.  As  a  matter  of  fact,  a  good  average  milk  is  more  likely  to  be 
obtained  from  mixing  the  milk  of  a  number  of  cows  than  in  taking  it  from  one,  for 
it  is  well  known  that  the  first  portion  of  milk  obtained  from  the  udder  is  poor  in 
fat,  while  the  last  portions  are  rich,  the  amount  varying  from  two  to  eight  per  cent. 
If  the  first  part  of  the  milk  taken  is  reserved  for  the  infant,  it  is  tolerably  certain 
to  get  a  poor  milk.  Whenever  a  cow  is  specially  reserved  to  supply  milk  for  an 
infant,  care  should  be  taken  to  see  that  it  is  not  an  old  one,  and  the  last  portions 
of  milk  should  be  taken  for  the  child. 

What  is  of  far  more  importance  than  the  question  of  "  one  cow"  is  the  question 
as  to  how  the  cows  are  fed,  and  the  care  taken  to  prevent  the  contamination  of  the 
milk  with  organic  matters.  In  the  vicinity  of  our  large  towns  it  is  no  uncommon 
thing  to  see  cows  out  at  pasture  in  fields  watered  by  brooks  contaminated  with 
sewage,  of  which  they  freely  drink  ;  moreover,  they  are  extremely  likely  to  lie 
down  in  the  sewage  water,  and  their  udders,  and  consequently  the  milker's  hands, 
become  befouled  with  sewage.  In  the  winter  time  the  cows  are  frequently  fed 
largely  on  turnips  and  brewer's  grains,  instead  of  hay,  maize,  or  other  dry  fodder  ; 
possibly  also  their  sheds  are  infrequentl)'  cleaned  out  and  only  sparingly  supplied 
with  straw,  so  that  the  animals  lie  in  fseces  and  iheir  udders  may  be  seen  caked 
with  dried  excrement.  It  is  no  uncommon  thing  to  jind  a  greenish-looking  sedi- 
ment in  milk  from  second-rate  dairies,  due  to  contamination  of  fajcal  matters.  The 
storage  of  milk  is  an  exceedingly  important  matter,  for  milk  readily  absorbs  gases, 
and  is  readily  contaminated  when  kept  in  cellars  or  kitchens  pervaded  with  sewer- 
gas  or  the  emanations  of  decomposing  animal  substances.  The  temperature  at 
which  it  is  kept  is  also  important,  as  it  far  more  quickly  turns  sour  and  decomposes 
when  kept  in  a  warm  place  than  in  a  cool  place.  This  is  recognized  by  many  milk 
purveyors,  who  at  once  take  measures  to  cool  the  milk  directly  it  is  received  frorr 
the  cow.  According  to  Soxhlet  fresh  milk  turns  sour  and  curdles  at  the  following 
temperatures  and  times  : 

At  32°  C.  (90°  If.)  in  19  hours. 
At  25°  C.  (77°  F.)  in  29  hours. 
At  17^"  C.  (63.5°  F.)  in  63  hours. 
At  10"  C.  (40°  F.)  in  208  hours. 
At  0°  C.  (32°  F.)  in  3  weeks. 

BARLEY  WATER. 

Place  a  tablespoonful  of  best  pearl  barley  in  an  enamelled  saucepan,  add  a  pint 
of  water,  and  boil  for  a  few  minutes,  stirring  all  the  time  so  as  thoroughly  to  cleanse 
the  grain.  Pour  the  water  off  the  barley,  replace  by  a  pint  and  a  half  of  clean 
wrater,  and  %\m\ae:x  gently  for  an  hour,  and  strain.     Another  and  better  method  is 


Appendix  t^53 

to  use  barley  meal  prepared  from  Uie  whole  grain,  inasmueh  as  the  greater  part  of 
the  gluten  is  found  in  the  cells  lining  the  husk  (Jacobi).  The  grain  should  lie  well 
washed  and  ground  in  a  coffee-mill  kept  for  the  purpose.  The  barley  water  used 
durino-  the  early  months  of  infancy  should  be  a  thin  mucilaginous  fluid  ;  in  the  later 
months  it  should  be  thicker,  or  barley  jelly  may  be  used  to  thicken  the  milk 

OATMEAL    WATER. 

A  table-spoonful  of  coarsely-ground  oatmeal  should  be  placed  in  a  pint  of  water  ; 
simmer  gently  for  an  hour,  replace  the  water  evaporated. 

ARROWROOT    WATER. 

Take  two  tea-spoonfuls  of  best  arrowroot  and  a  pint  of  water  ;  simmer  for  five 
minutes,  stirring  constantly. 

WHEY, 

Warm  a  pint  of  milk  to  blood-heat  ;  add  a  tea-spoonful  of  '  artificial  rennet ;'  irr 
a  few  minutes  tlie  curd  will  have  separated  from  the  whey  ;  break  up  the  curd  with 
a  fork  and  allow  it  to  stand  till  the  curd  has  subsided  ;  decant  and  boil  the  whey. 
Whey  thus  prepared  may  be  given  to  a  newly-born  infant,  cream  or  milk  being 
added  according  to  its  powers  of  digestion.  Whey  with  some  added  brandy  is  use- 
ful as  a  substitute  for  '  white  wine  whey,'  and  generally  agrees  better. 

VEAL    TEA. 

Take  one  pound  of  veal  free  from  fat  and  bone,  cut  into  small  pieces  the  size  of 
dice,  place  in  a  covered  jar  with  a  pint  and  a  half  of  water  or  barley  water,  cold  ; 
place  in  an  oven  not  too  hot,  and  bake  for  three  or  four  hours — or  it  may  be  left  in 
the  oven  all  night ;  strain  and  remove  fat. 


SCRAPED    MEAT. 

Take  a  thick  rumpsteak  of  the  best  quality  ;  scrape  it  with  a  knife  until  reduced 
to  shreds.  A  sandwich  can  be  made  by  placing  a  small  portion  between  very  thin 
slices  of  bread  and  butter.  Some  children  will  take  the  meat  pulp  out  of  a  tea- 
spoon or  mixed  with  gravy  or  beef-tea.  Scraped  meat  can  also  be  prepared  from 
rumpsteak  which  has  been  frizzled  for  a  few  moments  on  a  quick  fire,  the  burnt 
outside  being  cut  off  before  being  scraped. 

RAW    MEAT    JUICE. 

P^inely  mince  a  pound  of  the  best  rumpsteak  freed  from  fat.  Place  in  an  earthen 
vessel  with  sufticient  cold  water  to  well  cover  it,  add  some  lump  sufjar,  and  let  it 
stand  for  four  hours.  Strain  through  muslin.  It  can  be  given  with  port  wine  if 
thought  desirable. 


854  Diseases  of  Children 


LINSEED  MEAL  POULTICE. 

Warm  a  basin,  pour  in  boiling  water  ;  sprinkle  in  the  meal,  stirring  vigorously, 
till  it  becomes  of  the  consistency  of  thick  porridge  ;  spread  on  tow  or  old  linen, 
tm^ning  in  the  edges  all  round  ;  before  applying  put  it  against  one's  cheek  to  feel 
that  it  is  not  too  hot.  Retain  in  position  with  a  broad  flannel  roller,  secured  with 
safety-pins.  Renew  every  four  hours  or  oftener.  The  poultice  should  not  exceed 
half  an  inch  in  thickness.  Ca.ution  is  necessary  in  poulticing  the  chests  of  infants, 
in  order  not  to  overload  the  chest  and  tire  out  the  respiratory  muscles. 

MUSTARD    POULTICES. 

These  may  be  made  in  a  similar  way  to  the  above,  the  mustard  being  mixed 
with  warm  water,  and  stirred  well  into  the  linseed  poultice.  One  part  of  mustard 
to  three  or  four  of  linseed  meal  may  be  used  for  infants  and  young  children,  kept  on 
for  four  hours,  and  repeated  according  to  the  amount  of  redness  produced. 

BRAN    POULTICES. 

Bran  poultices  are  preferable  to  linseed  poultices  when  the  weight  of  the  latter 
is  an  objection,  as  in  colic.  A  flannel  bag  is  filled  with  bran,  boiling  water  is  then 
poured  over  it  till  it  is  thoroughly  saturated  ;  it  is  then  wrung  dry  in  a  towel,  placed 
against  One's  cheek  to  test  the  temperature,  and  applied. 

HOT  FOMENTATIONS. 

Flannel  or  spongio-piline  may  be  used,  being  wrung  out  of  boiling  water  in  a 
towel,  sprinkled  with  laudanum  or  turpentine  according  to  the  effect  desired,  and 
applied.  The  fomentations  should  be  retained  in  position  by  means  of  a  flannel 
bandage. 

ANTIPYRETIC    METHODS. 

Sponging. — The  readiest  means  of  reducing  temperature  when  the  fever  is 
moderate  in  degree  is  by  sponging.  The  child  should  be  stripped  and  lie  upon  a 
blanket  or  sheet  with  a  waterproof  beneath  ;  a  large  sponge  should  be  used,  and  the 
face,  trunk,  and  extremities  sponged  for  five  or  ten  minutes.  The  water  used 
should  be  cold,  but  with  nervous  patients  it  is  well  to  begin  with  tepid  water.  If 
the  child  is  feeble  it  may  have  a  hot  bottle  to  its  feet  during  the  sponging.  Cold 
sponging  is  a  useful  and  safe  means  of  reducing  temperature  in  all  febrile  conditions, 
but  its  action  is  only  temporary. 

Packs. — The  efficacy  of  a  continuous  pack  in  reducing  temperature  depends 
upon  its  action  on  the  skin  in  producing  sweating,  the  cooling  effect  of  the  applica- 
tion of  the  wetted  sheet  being  temporary  only,  unless  frequently  reapplied.  Packs 
are  most  useful  in  conjunction  with  certain  drugs,  as  aconite  and  quinine.  To 
apply  a  cold  pack  a  sheet  should  be  wrung  out  of  cold  water  and  applied  to  the 
patient  from  the  neck  to  the  feet  ;  a  blanket  is  then  wrapped  around  the  sheet.     It 


Appendix  855 

should  be  reapjilied  in  a  quarter  of  an  liour  if  the  tempcralure  appears  liigh,  but 
frequently  the  patient  goes  to  sleep  in  the  pack,  and  it  may  be  wise  to  leave  him 
undisturbed,  for  an  hour  at  least.  Cold  packs  are  often  of  great  service  in  scarlet 
fever,  measles,  and  other  febrile  conditions.  In  pneumonia  packs  are  often  useful, 
the  wet  sheet  being  applied  only  round  the  chest. 

Baths. — The  cold  or  graduated  bath  is  the  most  rapid  means  of  reducing  a  high 
temperature,  and  has  the  advantage  of  being  readily  applied.  The  child  may  be 
l>laced  in  a  bath  of  ioo°  F.  and  the  temperature  of  the  bath  reduced  by  the  gradual 
addition  of  cold  water.  The  cold  water  may  be  poured  over  the  patient's  head  if 
the  temperature  is  high.  Cold  baths  may  be  used  in  enteric,  pneumonia,  measles, 
indeed  in  a  high  temperature  from  any  cause  excepting  scarlet  fever  or  diphtheria. 
In  severe  attacks  of  these  diseases  the  cold  bath  is  apt  to  depress  too  much,  the 
patient  becoming  cold  and  collapsed. 

Enema. — Enemata  of  cold  water  have  been  successfully  used  in  reducing  tem- 
perature, but  can  only  be  of  limited  application. 

Ice-bags. — Ice  applied  to  the  head  or  chest  in  a  rubber  bag,  or  flannel  wrung 
out  of  ice  and  water,  form  effectual  means  of  reducing  temperature. 

Aconite. — Given  in  the  form  of  tincture,  is  useful  as  an  antipyretic  in  conjunc- 
tion with  packs.  It  is  necessarily  of  limited  application  on  account  of  the  depres- 
sion it  produces  if  pushed.  A  quarter  to  one  minim  may  be  given  every  hour  in 
pneumonia,  the  effect  being  carefully  watched. 

Quinine. — Quinine  may  be  given  to  reduce  temperature  in  doses  of  two  to  ten 
grains  of  the  sulphate  in  syrup  of  orange-peel,  milk,  or  cocoa  ;  it  is  useful  for  this  pur- 
pose in  conjunction  with  packs  in  malaria,  scarlet  fever,  pneumonia,  and  measles. 
If  given  by  the  rectum,  the  neutral  bisulphate  should  be  used,  or  the  sulphate 
should  be  dissolved  with  the  least  possible  excess  of  acid.  It  is  well  to  bear  in  mind 
that  it  is  useless  to  expect  absorption  from  a  rectum  loaded  with  faeces,  and  a 
drachm  of  glycerine  must  be  administered  in  order  to  relieve  the  bowels  before  in- 
jecting the  quinine.  The  quantity  given  by  rectum  must  be  double  that  given  by 
mouth. 

The  subcutaneous  injection  of  quinine  is  not  often  resorted  to  in  infants,  inas- 
much as  a  neVitral  solution  is  not  often  at  hand  when  wanted.  In  a  high  tempera- 
ture due  to  malaria  it  would  be  of  service. 

Antifebrin. — This  drug  is  much  used  at  the  present  time  in  reducing  high 
temperatures.  It  maybe  given  in  the  form  of  powder  ;  or  in  wine,  as  it  is  insolu- 
ble in  water.  It  is  better  to  begin  with  a  small  dose  and  to  repeat  every  three  or 
four  hours  if  necessary.  One-grain  doses  may  be  given  under  two  years  of  age,  two 
grains  from  two  to  four  year?  of  age,  three  to  four  grains  for  older  children,  and 
repeated  if  necessary  every  four  hours.  An  overdose  is  apt  to  produce  cyanosis, 
weak  pulse,  and  profuse  sweating.  This  drug  is  useful  in  acute  pneumonia,  measles, 
typhoid,  and  scarlet  fever.  The  continuous  use  of  it  should  be  avoided  if  there  are 
any  symptoms  of  cardiac  failure;  toxic  symptoms,  especially  jaundice  and  albumi- 
nuria, may  arise. 

Antipyrine. — -This  drug  is  used  in  a  similar  way  to  antifebrin  ;  the  dose  given- 
must  be  twice  as  large  to  produce  the  same  eflect. 

Phenacetin  is  another  drug  of  the  same  series,  and  may  be  given  in  doses  of  the 


856  Diseases  of  Children 

same  size  as  antifebrin.     This  is  much  preferred  in  the  United   States  to  other 
•drugs  of  its  class,  as  being  safe  and  equally  effective. 

HOT    PACKS. 

Hot  packing  is  most  useful  in  nephritis,  especially  when  the  kidneys  are  choked.- 
A  blanket  is  wrung  out  of  hot  water  as  dry  as  possible  and  quickly  applied,  care 
being  taken  that  it  is  not  too  hot;   it  may  be  renewed  in  half  an  hour. 

HOT    AIR    OR    VAPOUR    BATHS. 

These  are  useful  under  similar  circumstances  to  the  hot  pack  ;  they  are  best  ap- 
plied by  means  of  a  special  apparatus,  Allen's  being  the  best.  A  hot  vapor  bath 
can  be  improvised  for  a  child  with  a  'bronchitis  kettle,'  or  even  an  ordinary  ket- 
tle, and  spirit  or  paraffin  lamp,  a  chair  being  used  as  a  '  cradle.'  There  is,  how- 
ever, some  risk  of  accident. 

MUSTARD    BATH. 

An  ounce  of  mustard  to  a  gallon  of  water  (100°  r.)is  the  right  proportion.  The 
mustard  should  be  made  into  a  paste  in  a  basin,  and  gradually  stirred  into  the 
-water  of  the  bath.  Useful  in  diarrhoea,  pneumonia,  or  collapse  from  any  cause  j 
jiiore  especially  in  infants  and  young  children. 

NARCOTICS. 

Opiates. — Infants  are  sensitive  to  the  action  of  opium,  and  this  drug  requires 
to  be  administered  with  great  caution  and  its  effect  carefully  watched.  At  the  same 
time  there  cannot  be  a  doubt  as  to  its  value  in  many  instances,  particularly  in  reliev 
ing  pain  and  quieting  the  overaction  of  the  bowels.  In  prescribing  it  to  infants, 
not  only  the  question  of  age,  but  also  the  size  of  the  child,  and  the  complaint  from 
which  it  is  suffering,  and  the  degree  of  exhaustion  present,  must  be  borne  in  mind. 
It  is  obvious  that  the  dose  of  opium  suitable  for  a  strong,  well-nourished  infant  of 
six  months  of  age,  suffering  from  colic,  might  be  unsafe  if  given  to  an  infant  of 
eighteen  months  in  the  last  stages  of  gastro-intestinal  atrophy.  Infants  in  the  last 
stages  of  diarrhoea,  atrophy,  and  pneumonia  are  exceedingly  sensitive  to  opium, 
and  caution  should  be  observed  in  giving  it  to  them.  Moreover,  such  infants  pass 
sometimes  into  a  comatose  state  before  death,  not  unlike  the  condition  produced 
•by  opium  poisoning,  and  under  these  circumstances  the  immediate  cause  of  death 
might  be  attributed  to  opium.  As  a  general  rule,  and  presuming  the  infant  is  a 
well-nourished  one,  \  grain  of  Dover's  powder  may  be  given  to  an  infant  of  six 
months  and  repeated  in  four  hours  if  necessary.  Larger  doses  may  be  given  with 
safety  if  the  infant  can  be  watched,  and  indeed,  if  the  infant  is  suffering  from  acute 
•colic  or  intussusception,  twice  or  even  four  times  the  dose  named  may  be  given. 
In  one  case  coming  under  our  observation,  -;j'^-  grain  of  acetate  of  morphia  was  given 
to  a  strong  infant  four  months  of  age  suffering  from  acute  abdominal  pain  ;  the 
infant  became  drowsy,  the  pupils  were  semi-contracted,  it  remained  in  a  semi- 
vcomatose  state  with  sighing  respiration  for  two  or  three  hours,  when  it  woke  up 


Appendix  .  857 

perfectly  well.  It  was  evident,  however,  that  the  limit  of  safety  had  been  passed. 
Three  grains  of  pulv.  kino  co.  (Br.)  were  given  to  an  infant  of  six  months,  who  was 
much  wasted  and  suffering  from  diarrhoea,  at  intervals  of  four  hours,  three  doses 
being  given  in  all.  The  second  dose  made  it  drowsy  ;  it  died  a  few  hours  after  the 
third  dose,  with  all  the  symptoms  of  opium  poisoning.  It  had  taken  in  all  nearly 
\  grain  of  opium.  One  grain  of  Dover's  powder,  or  a  minim  (^^-\^y\  grain)  of  liq. 
nuirphia,  is  an  average  dose  for  on  infant  a  year  old,  and  may  be  repeated  in  two 
or  four  hours  if  necessary.  Two  or  three  grains  of  Dover's  powder,  or  two  or  three 
minims  of  liq.  morphince,  may  be  given  to  children  between  two  and  four  years  of 
age.  Children  over  six  years  of  age  are  much  less  sensitive  to  opium  than  younger 
children,  and  J  to  ■!■  grain  of  opium  may  be  given  if  necessary  to  relieve  pain  in 
peritonitis  or  other  diseases.  It  must  be  borne  in  mind  that  idiosyncrasies  may  be 
met  with,  and  infants  may  be  found  exceedingly  sensitive  to  opium,  or,  on  the 
other  hand,  very  tolerant. 

Subcutaneous  injections  of  morphia  are  best  avoided  in  infants  under  a  year,  and 
are  not  often  reauired  for  young  children  ;  -^-^  grain  would  be  a  full  dose  for  an 
infant  of  a  year. 

Codeine  is  of  some  value  in  relieving  pain  in  children,  especially  in  connection 
with  the  alimentary  system.  It  may  be  given  in  syrup  of  orange.  It  may  be  given 
in  doses  of  -|\>-o  grain  to  infants  and  young  children,  and  \-\  grain  to  older  chil- 
dren. It  is  useful  in  colic,  diarrhoea  with  tenesmus,  and  irritative  cough — in  the 
latter  perhaps  not  so  good  as  morphia. 

Chloral  hydrate. — Chloral  is  soluble  in  water,  and  maybe  given  2  or  2-i-  grains 
to  the  drachm  of  cinnamon  water,  sweetened  with  syrup  of  orange.  Infants  and 
children  tolerate  chloral  well  ;  its  principal  use,  combined  with  bromide,  is  in 
convulsions  and  to  procure  sleep.  It  is  of  but  little  use  in  relieving  pain.  2-J-5 
grains  may  be  given  to  children  from  a  year  to  two  years  old.  5-10  grains  may  be 
given  to  older  children.  Very  much  larger  doses  have  been  given  to  procure  an- 
CESthesia  (Bouchut). 

Bromide  of  potassium. — 2.-z\  grains  to  the  drachm  of  water  sweetened  with 
syrup  of  orange  or  lemon,  and  spirit  of  chloroform.  The  liquid  extract  of  liquor- 
ice hides  the  taste  fairly  well.  3-5  grains  may  be  given  to  cliildren  from  a  few 
weeks  to  two  years  of  age,  and  repeated  every  two  hours  if  necessary.  20-60  grains 
a  day  may  be  given  to  older  children  who  are  suffering  from  cerebral  excitement  or 
fits.  There  is  little  risk  in  an  overdose  ;  children  well  under  the  influence  of  bro- 
mide are  lethargic,  speak  with  a  slow  drawling  tone,  and  suffer  from  acne. 

Antipyrine  acts  as  a  sedative  in  small  doses  in  infants  and  young  children  ; 
\-\  grain  may  be  given  to  infants  suffering  from  colic  or  painful  dentition. 

Belladonna  and  atropine  are  much  used  in  whooping-cough,  incontinence  of 
urine,  and  as  external  applications.  Children  are  tolerant  of  these  drugs,  and 
larger  proportional  doses  than  those  given  to  adults  may  be  prescribed,  if  they  are 
carefully  watched.  Children  of  one  to  two  years  of  age  may  be  given  1-3  drops  of 
the  tincture  every  four  hours.  Older  children,  2-7  minims  or  more,  though  it  is 
wiser  to  begin  with  minimum  doses  and  gradually  increase  the  dose.  Atropine  is 
more  dangerous,  and  is  best  avoided  in  young  children.  Children  five  years  old 
and  upward  may  be  given   minim   doses  (j^y   grain)  of  the  liquor,    cautiously  in- 


858  Diseases  of  Children 

creased.  Temporary  excitement  and  dilated  pupils  are  the  result  of  an  over- 
dose. 

Cannabis  indica. — Children  bear  this  drug  well ;  it  is  usefully  added  to  bromide 
in  2-J  minim  to  10  minim  doses  of  the  tiacture  in  whooping-cough. 

Hyoscyamus. — Tincture  of  hyoscyamus  is  used  as  an  anodyne  in  place  of 
opium.  Its  nauseous  taste  is  one  objection  to  it ;  it  may  be  given  in  5-minim  doses 
to  an  infant  a  year  old,  10-30  minims  to  older  children. 

Hyoscyamine  sulphate  is  frequently  substituted  for  the  tincture,  but,  like 
atropine,  it  must  be  used  cautiously,  or  not  given  at  all  to  infants,  ^^^-g  gr.,  cau- 
tiously increased  to  g\,-  gr. ,  may  be  given  to  older  children  ;  larger  doses  have  been 
given. 

Hyoscine  may  be  given  with  caution  in  the  same  doses  as  above,  but  is  said  to 
be  more  active. 

PURGATIVES  AND  LAXATIVES. 

Mercury  and  chalk  by  itself,  or  in  combination  with  rhubarb  and  soda,  is 
very  frequently  given  as  a  laxative  for  infants  a  few  months  old,  or  when  the  stools 
indicate  some  irritative  matters  in  the  bowels.  For  this  purpose  \-2  grs.  may  be 
given  twice  a  day  for  a  few  days,  or  for  two  or  three  successive  nights. 

Calomel  is  preferable  for  older  children  on  account  of  the  smaller  dose  required; 
it  may  be  given  with  soda,  euonymin,  rhubarb,  scammony,  or  jalapine.  A  grain 
may  be  given  with  white  sugar  to  a  child  of  one  to  three  years,  half  a  grain  to  an 
infant  of  six  months,  as  a  purgative.  Half  the  quantity  may  be  given  with  other 
drugs  ;  thus — calomel,  gr.  -^  ;  scammony  resin,  gr.  ^  ;  calomel,  gr.  -J  ;  pulv.  rhei,  gr. 
■J;  sodse  bicarb.,  gr.  ^  ;  calomel,  gr.  -J;  euonymin,  gr.  -J.  Small  pilules  made  of 
calomel,  gr.  ^  ;  ex.  colocynth.  co.,  gr.  f  ;  calomel,  gr.  ^  ;  ex.  rhei,  gr.  f,  answer  very 
well.  Some  prefer  to  give  small  doses  of  this  drug,  as  gr.  ^,  repeated  every  hour 
till  the  bowels  act. 

Rhubarb  forms  a  safe  and  non-irritative  purgative,  and  is  especially  useful  in 
combination  with  soda  when  a  laxative  and  stomachic  is  required.  It  unfortunately 
has  a  nauseous  taste,  best  covered  by  syrup  of  orange  or  spirits  of  nutmeg.  Tab- 
loids of  rheum  c.  soda  are  very  convenient. 

The  syrup  is  a  good  preparation,  especially  in  combination  with  an  equal  quan- 
tity of  syrup  of  senna,  of  which  half  a  tea-spoonful  to  a  spoonful  is  a  dose.  'Mist. 
rhei  co.'  is  much  used  as  a  laxative,  given  two  or  three  times  a  day,  especially  in 
infants  when  the  stools  are  'putty-like  '  and  sour-smelling  ;  thus,  syrup,  rhei,  TH^xx  y 
sodas  bicarb.,  gr.  j;   aq.  menth.  pip.,    3  j. 

Inf.  rhei  with  sodse  carb.  and  sp.  amnion,  aromat.  forms  a  useful  carminative 
for  infants — such  as  sp.  ammon.  aromat.,  711  iii  ;  soda;  bicarb.,  gr.  ii ;  syrup,  zingib., 
TTl^xx ;  inf.  rhei  ad  3j;  sp.  ammon.  aromat. ,  TfLiiss  ;  syrup,  zingib.  Tl^xx ;  inf. 
rhei,  T(]^xv  ;  inf.  gent.  co.  ad   3  j- 

Aloes. — Much  used  for  constipation,  either  in  the  form  of  the  aq.  ext.  or  aloin 
in  pilules.  Small  pilules  containing  ^  grain  of  aq.  ext.  of  aloes  are  readily  swal- 
lowed by  children,  or  they  can  be  divided  with  a  knife  and  given  in  jam.  Aloin  is 
useful  in  treating  the  constipation  of  infants  and  young  children  ;  '  anticonstipa- 
tion'  'tabloids,'  containing  aloin,  gr.  \,  belladonnse  ext.,  gr.  \,  stryclmine,  gr.  -g^j, 


Appendix  859 

ipecac,  gr.  -.-V,  may  be  used,  half  a  one  being  given  to  infants  once  or  twice  a  day, 
mixed  with  a  little  white  sugar. 

Senna. — Mostly  given  in  the  form  of  the  compound  liquorice  powder,  syrup,  or 
infusit)n.  The  former  is  much  used  as  a  household  medicine,  quarter  to  one  tea- 
spoonfuls  being  given  mixed  with  a  little  water.  The  syrup  is  pleasanter  to  take,  be- 
ing free  from  any  grittiness  ;  a  tea-spoonful  is  the  usual  dose ;  it  is  most  effective 
when  given  with  an  equal  quantity  of  syrup  of  rhubarb.  The  infusion  is  given  in 
constipation  with  some  bitter,  as  strychnine  or  calumba,  such  as  liq.  strychnia;, 
TlLss  ;  glycerine,  ITl^x  ;  inf.  sennte,  TT^xx  ;  inf.  calumbse,  ad  3  j,  b.  or  t.  d.  s.  Old 
preparations  of  senna  are  apt  to  gripe. 

Cascara  sagrada  is  of  much  value  in  habitual  constipation  in  infants  and  chil- 
dren. It  may  be  given  in  syrup  or  some  of  the  elixirs,  chocolate  bonbons  or  loz- 
enges. Some  chemists  prepare  an  extract  from  which  the  bitter  principle  has  been 
removed.      Five  to  20  minims  of  the  liquid  extract  once  a  day  is  the  usual  dose. 

Podophyllunn  resin  may  be  given  in  powder  or  '  tabloid  '  form  to  infants  and 
children  suffering  from  constipation,  beginning  with  ^V  gr.  to  -jV  gr.  two  or  three 
times  a  day.  Liq.  podophylli  (gr.  i  ad  3  j),  made  by  some  chemists,  is  a  useful 
preparation,  and  may  be  prescribed  with  strychnine,  bitters,  acids,  or  alkalies. 

Rubinat,  Hunyadi  Janos,  Carlsbad  mineral  waters — a  table-spoonful  or 
more  in  warm  water  or  milk,  given  before  breakfast — are  very  useful  purgatives  for 
children  over  four  years  of  age. 

EMETICS. 

Pulv.  ipecac,  is  the  best  and  safest  emetic  for  children.  It  may  be  kept  in 
the  form  of  powder  or  the  5  grain  '  tabloids.'  Five  grains  may  be  given,  and  re- 
peated every  ten  minutes  till  vomiting  is  produced,  to  infants  and  young  children. 
Ten  grains  may  be  given  in  one  dose  to  older  children,  and  repeated  in  ten  minutes 
or  a  quarter  of  an  hour.  There  is  great  difference  in  children  with  regard  to  the  ease 
with  which  they  are  made  to  vomit.  In  the  later  stages  of  croup  or  pneumonia, 
when  the  face  and  lips  are  pale  or  bluish,  it  is  difticult  to  excite  vomiting  ;  indeed 
at  this  stage  emetics  are  useless. 

Apomorphia  is  apt  to  depress  too  much  ;  it  may  be  given  aTj-Zu  §•"•  subcutane- 
ously,  but  not  to  infants. 

Alum. — Half  a  tea-spoonful  in  honey  or  syrup  is  useful  in  whooping  cough. 

EXPECTORANTS    AND    DIAPHORETICS. 

Ipecacuanha  is  usually  given  in  the  form  of  vinum  ipecac,  in  doses  of  TH_iiss- 
Tfl.v  to  infants  up  to  a  year  old,  KTl^v-lfT^xv  to  older  children,  repeated  every  two  to 
four  hours.  It  may  be  given  v/ith  Tl^v-x  of  aq.  laurocerasi  and  TTJ^x  of  glycerine  to 
the  drachm  of  water  ;  or  syrup  pruni  virgin,  may  be  added.  Vin  ipecac,  is  apt  to 
lose  its  strength  by  keeping. 

Pulv.  ipecac,  co.  is  a  useful  expectorant  (see  Opium). 

Antimony. — Mostly  given  as  vinum,  in  the  same  doses  as  vin.  ipecac;  often 
prescribed  with  mist,  amygdalte.  Both  ipecac,  and  antimony  are  better  given  in 
small  doses,  frequently  repeated,  than  in  increasing  doses.  In  acute  bronchitis  or 
laryngitis  it  is  often  useful  to  push  either  ipecac,  or  antimony  freely  till  sickness  is 


86o  Diseases  of  -Children 

produced,  then  to  lessen  the  dose.  Both  these  drugs  are  given  in  the  early  stage 
of  bronchitis  when  rhonchi  and  sibilus  are  heard. 

Emetine. — Dose  tutt-'iV  gr. ;  not  often  prescribed. 

Liq.  ammon.  citratis  or  liq.  ammon.  acet.  is  often  combined  with  vin.  ipecac, 
or  vin.  antimon.  in  doses  of  TT^xv-TTl^xx  for  infants  up  to  a  year,  3  ss  to  3  j  for 
older  children,  well  diluted,  with  syrup  tolu,  aurant.,  or  pruni  virgin,  to  cover 
the  taste. 

Sp.  ammon.  aromat. — Dose  'Tri_ii-Tfl_iii  in  a  drachm  of  syrup  or  glycerine  and 
water  for  infants  ;   TT^^iv-TTLx,  well  diluted,  for  older  children. 

Ammon.  carbonat,  or  chloride.  Dose  :  gr.  iss-gr.  v,  well  diluted,  and  dis- 
guised as  far  as  possible  by  syrup  aurant.,  tolu,  or  scillae. 

Squills. — Useful  as  a  stimulating  expectorant  in  bronchitis,  when  the  secretion 
is  free,  fluid  rales  being  heard  in  the  chest,  and  but  little  being  coughed  up.  l^mc- 
ture  :  doses  TH,ii-1!T[^iii  for  an  infant  up  to  a  year  old  ;  Tfl^iii-Tl\^v  for  older  children, 
repeated  every  four  hours.  Syrup  or  oxy-inel  :  Tl\x-  3  ss.  The  syrup  is  often  com- 
bined with  ipecac,  or  ammonia,  according  to  the  stage  of  the  bronchial  affection. 

Terebene. — Often  useful  as  a  stimulating  expectorant ;  not  often  given  inter- 
nally to  infants.  TTlii  to  1Tl_v  may  be  given  on  sugar  to  older  children,  or  suspended 
in  mucilage  and  syrup  of  lemon. 

ANTACIDS    AND    CARMINATIVES. 

Alkalies  and  aromatics  are  frequently  required  in  the  dyspepsias  of  infancy.  Of 
the  former,  sodae  bicarb,  gr.  iiss,  magnesice  carb.  gr.  iii,  combined  with  syrup 
zingib.  and  aq.  anisi  ad  3  j,  is  useful  ;  or  sodas  bicarb,  gr.  iiss,  tr.  nucis  vomicte, 
'W,  tr.  cardamom,  co.  TT^v,  sp.  chloroformi,  ITLiiss,  aq.  anethi,  ad  3  j,  given  occa- 
sionally. 

TONICS. 

Cod-liver  oil  takes  the  first  place.  It  is  best  given  after  meals  and  in  the  form 
of  an  emulsion  ;  some  of  the  latter  are  to  be  obtained  combined  with  lime  salts, 
TH^x  to  ITl^xx  of  the  oil  twice  or  three  times  a  day  is  the  dose  for  infants ;  3  ss  to 
3  j  may  be  given  to  older  children.  Dyspepsia,  catarrh  of  intestines,  and  diarrhoea 
should  be  treated  before  cod-liver  is  given.  Inunctions  of  warm  cod-liver  are  often 
useful  ;  the  oil  is  applied  on  a  sponge  and  the  child  clothed  in  a  flannel  nightdress. 

Acids. — Dilute  nitric  acid  (Tfl^iss  to  ITl^ii,  aq.  ad  3  j)  is  often  of  much  service  dur- 
ing convalescence.  It  may  be  combined  with  tr.  cinchonse  co.,  or  decoc.  cinchonas 
and  syrup  limonis. 

Iron. — Often  given  as  vinum  ferri,  Tfl^x  to  3  j,  syrup  ferri  phos.  co.  TT^x  to  3  j,  or 
tr.  ferri  perchlorid.  11^1  to  TTl,ii,  in  a  wineglass  of  water  at  meal  times.  Ferri  et 
ammon.  cit.  may  be  combined  with  alkalies  and  nux  vomica. 

STIMULANTS. 

Alcohol  necessarily  takes  the  first  place  in  the  list,  and  is  beyond  all  question 
of  value  in  treating  acute  disease  when  there  is  evidence  of  a  flagging  heart.  It  is 
jiot  a  matter  of  much  importance  what  form  of  alcohol  is  selected,  presuming  it  is 


Appendix  86 1 

of  good  quality.  Brandy,  in  the  form  of  mist.  sp.  vini  gallici,  "is  the  one  perhaps 
most  generally  useful.  In  hospital  whiskey  frequently  takes  the  place  of  brandy 
for  the  sake  of  economy.  Cura9oa,  champagne,  port  wine,  more  or  less  diluted 
according  to  circumstances,  may  be  used.  Alcoholic  stimulants  are  called  for  in 
the  adynamic  forms  of  scarlet  fever,  diphtheria,  broncho-pneumonia,  acute  diar- 
rhoea, and  other  allied  conditions.  The  pulse  is  the  best  guide  :  a  feeble,  irregular, 
intermittent  pulse  calls  for  alcohol,  mere  rapidity  of  pulse  does  not.  Drowsiness,  if 
it  does  not  contra-indicate  alcohol  at  least  calls  for  caution  in  its  administration, 
as  overdosing  with  alcohol  is  apt  to  make  the  drowsiness  more  pronounced,  espe- 
cially that  form  due  to  a  hypervenous  condition  of  blood.  Delirium  is  often  made 
worse  by  alcohol,  especially  if  there  is  evidence  of  cerebral  congestion,  the  con- 
junctival vessels  being  injected  as  in  the  early  days  of  scarlet  fever.  In  such  cases 
opium  or  bromide  answers  better.  Vomiting  is  a  signal  for  discontinuing  alcohol, 
for  a  while  at  least.  Unfortunately  champagne,  so  useful  as  a  rapidly  diffusable 
stimulant,  is  apt  to  produce  sickness.  The  amount  of  alcohol  given  necessarily 
depends  upon  circumstances  :  drachm  doses  of  brandy,  or  even  more,  every  hour, 
may  be  given  in  some  cases  of  scarlet  fever  or  broncho-pneumonia,  with  advantage 
even  to  young  children.  In  infants  alcohol  is  principally  of  value  in  colic  and  acute 
diarrhoea,  and  may  be  given  well  diluted  with  barley  water,  arrowroot,  or  milk. 
Port  wine  sometimes  seems  to  agree  better  than  spirit.  In  chronic  disease  alcohol 
is  of  less  value  than  in  acute,  as  the  long-continued  administration  of  it  certainly 
has  its  evils,  and  is  apt  to  produce  d5'spepsia  and  sluggish  liver.  In  anaemia,  scro- 
fulosis,  and  tuberculosis  the  wine  of  St.  Raphael,  port  wine,  or  porter  may  some- 
times be  given  with  advantage.  [Also  see  Heart-stimulant,  under  Pneumonia,  p. 
374-] 

FORCED  FEEDING.  GAVAGE. 

Difficulties  sometimes  arise  in  feeding  immature  infants  and  those  with  cleft 
palates,  the  infant  being  too  weak  to  suck  ;  or  the  conformation  of  the  mouth  may 
render  this  impossible.  In  diphtheria,  when  the  tonsils  are  enlarged  and  painful, 
or  in  paralysis  of  the  pharynx,  '  forced  feeding  '  may  have  to  be  resorted  to.  P'or 
weakly  infants  the  '  fountain '  feeding  bottles  have  been  devised,  and  the  '  bibe- 
vons  pompes '  of  the  French  ;  there  is,  however,  no  difficulty  in  feeding  a  weakly 
infant  by  means  of  the  ordinary  boat-shaped  feeder  if  held  slightly  inclined.  In- 
fants with  cleft  palates  have  to  be  fed  by  spoon  or  hy  means  of  the  '  Scott-Battams 
method,'  namely,  a  piece  of  india-tubing  attached  to  a  glass  syringe.  In  difficulty 
of  swallowing  from  any  cause  this  last  method  is  the  most  generally  useful.  An 
ordinary  glass  syringe  is  taken  and  filled  with  milk,  beef-tea,  or  other  liquid  nour- 
ishment, a  piece  of  india-rubber  tubing  a  few  inches  long  is  attached,  the  latter  is 
passed  into  the  mouth  to  the  back  of  the  tongue,  and  the  piston  of  the  syringe  slowly 
pressed  from  time  to  time,  so  that  small  quantities  of  fluid  are  swallowed  from  time 
to  time.  The  tube  need  not  be  passed  between  the  teeth  ;  if  the  latter  are  clenched 
the  tube  may  be  passed  between  the  cheek  and  the  jaws.  In  cases  where  the  pha- 
rynx is  completely  paralysed  a  medium-sized  india-rubber  catheter  must  be  jDassed 
through  the  nose  into  the  pharynx  and  oesophagus,  and  food  introduced  into  the 
stomach. 


862  Diseases  of  Children 

Forced  feeding  has  also  been  used  by  Dr.  Kerley,  of  New  York,  in  cases  of  per- 
sistent vomiting  in  young  infants,  his  experience  being  that  food  introduced 
directly  into  the  stomach  by  a  tube  and  funnel  is  less  readily  rejected  than  if 
swallowed  in  the  ordinary  way.  His  method  is  as  follows  :  The  infant  is  held  in  a 
half  reclining  posture  on  the  nurse's  right  arm  ;  a  soft  india-rubber  catheter,  at- 
tached to  a  funnel  of  three  or  four  ounces  capacity  by  a  rubber  tul:)e  two  and  a  half 
feet  long,  is  rapidly  introduced  into  the  stomach,  a  half  to  two  and  a  half  ounces 
•  of  liquid  food  introduced  into  the  funnel  ;  the  latter  is  then  raised  and  when  empty 
rapidly  withdrawn.  This  method  of  forced  feeding  appears  to  be  more  successful 
in  infants  than  in  older  children.  A  preliminary  stomach  washing  should  precede 
the  first  forced  feeding. 

STOMACH   WASHING. 

Washing  out  the  stomach  is  often  a  highly  beneficial  proceeding  in  the  dyspep-- 
sias  of  infants,  esjDecially  when  vomiting  of  decomposing  curd  is  a  prominent  symp- 
tom. The  removal  of  curd  which  may  have  remained  in  the  stomach  for  some  days, 
as  well  as  the  acid  mucus,  is  certain  to  be  beneficial.  The  method  of  carrying  it  is 
the  same  in  infants  as  in  adults.  An  india-rubber  catheter  as  large  as  possible  is 
passed  down  the  pharynx  into  the  stomach,  and  connected  by  means  of  an  india- 
rubber  tube,  two  or  three  feet  in  length,  with  a  funnel.  One  or  two  ounces  of 
warm  two  per  cent,  solution  of  borax  is  introduced  into  the  tunnel  ;  the  latter  is 
raised  so  that  the  fluid  flows  into  the  stomach,  and  then  lowered  and  inverted  so  as 
to  allow  of  the  return  of  the  fluid  contents  of  the  stomach.  This  proceeding  is 
repeated  till  the  returning  fluid  is  clean  and  sweet.  Curdy  material  often  escapes 
by  the  side  of  the  tul:)e. 

Stomach  washing  is  useful  not  only  in  the  chronic  dyspepsias  of  infancy,  but 
also  in  the  vomiting  of  acute  gastric  catarrh  and  other  forms  of  vomiting. 

ENEMATA. 

Enemata  are  required  for  various  purposes  during  infancy  and  childhood.  A 
simple  enema  may  be  required  to  unload  the  bowels  and  clear  away  scybala  which 
have  collected  in  the  large  bowel  ;  or  they  may  be  given  for  other  purposes,  such 
as  that  of  applying  local  treatment  to  the  mucous  membrane  of  the  colon,  to  re- 
place an  invagination,  or  to  destroy  oxyurides  which  are  present  there.  Rectal  in- 
jections are  also  resorted  to  as  a  means  of  administering  drugs  or  nutriment. 

Purgative  enemata  are  generally  given  with  a  fountain  syringe,  and  at  a  temper- 
ature of  about  iGO°.  They  may  consist  of  soap  and  water  with  the  addition  of 
olive  oil,  castor  oil,  or  turpentine.  When  the  latter  is  used  a  teaspoonful  of  ol. 
terebinth.,  two  teaspoonfuls  of  olive  oil,  and  the  yolk  of  an  egg  may  be  shaken  up 
with  four  or  five  ounces  of  water  for  a  child  of  two  or  three  years.  A  large  quan- 
tity of  fluid  may  be  injected  if  the  fluid  is  required  to  reach  the  upper  part  of  the 
large  bowel.  Some  care  is  required,  in  giving  an  injection,  to  do  it  slowly,  avoid- 
ing all  force.  If  it  is  required  simply  to  unload  the  lower  bowel,  an  injection  of  a 
teaspoonful  of  glycerine  is  all  that  is  required.  Enemata  for  the  destruction  of  the 
oxyurides  are  best  given  after  a  sharp  purgative  has  been  administered,  in  order  to 


Appendix  863 

drive  the  parasites  as  much  as  possible  into  the  lower  part  of  the  intestines.  For 
this  purpose  the  turpentine  injection  referred  to  above  answers  very  well,  or  half  a 
pint  to  a  pint  of  corrosive  chloride  of  mercury  (i  to  2,000)  may  be  used.  Re- 
peated '  irrigation '  of  the  large  bowel  has  been  much  practised  on  the  Continent 
{Monti,  Baginsky)  in  various  diseased  conditions,  such  as  constipation,  dysenteric 
diarrhoea,  catarrh  of  the  large  bowel,  &c.  Large  quantities  of  water  or  various 
solutions  are  injected  by  means  of  an  india-rubber  tube  with  a  nozzle  to  fit  in  the 
rectum,  and  a  funnel.  The  forcing  of  a  large  quantity  of  fiuid  into  the  colon,  es- 
pecially in  young  children,  is  not  always  easy,  on  account  of  the  straining  and 
struggling  which  it  is  apt  to  produce,  and  forcible  injection  of  fluid  by  means  of 
raising  the  funnel  with  tube  attached  is  not  free  from  danger.  In  irritable  condi- 
tions of  the  colon  warm  mucilaginous  fluids,  such  as  decoction  of  arrowroot,  two 
to  four  ounces,  with  two  to  five  minims  of  laudanum,  is  soothing,  and  relieves  tenes- 
mus. The  subnitrate  of  oxide  of  bismuth,  suspended  in  mucilage,  and  three  or 
four  ounces  injected,  is  also  useful.  In  more  chronic  cases,  alum,  zinc,  sulphate,  or 
nitrate  of  silver  may  be  used.  On  the  whole,  opiates  are  the  most  comforting  to 
the  patient. 

Nutrient  enemata  may  be  given  of  peptonised  beef-tea,  or  milk  with  brandy,  or 
some  other  form  of  alcohol. 

DIRECTIONS    FOR   USE    OF    DISINFECTANTS. 

Solution  A. — Chloride  of  lime,  eight  ounces  ;  soft  water,  one  gallon. 

Solution  B. — Liq.  sodse  chlorinatse,  one  part ;  soft  water,  five  parts. 

Solution  C. — Corrosive  chloride  of  mercury,  four  ounces  ;  permanganate  of 
potash,  one  dram;   soft  water,  one  gallon. 

Stock  bottles  to  be  kept  locked  up,  and  labelled  '  POISON.' 

For  use  : — one  fluid  ounce  to  be  mixed  with  one  gallon  of  water. 

Use  of  A. — For  the  disinfection  of  excreta  :  Mix  well  with  each  stool  half  a 
pint  of  solution  A,  and  allow  it  to  stand  for  ten  minutes  before  emptying  it  into  the 
closet.  Treat  the  vomit  of  fever  patients  similarly,  and  keep  the  sputa-cups  of 
phthisical  patients  half  full  of  the  same  solution. 

Use  of  B. — (i)  For  the  washing  of  hands  and  the  cleansing  of  spatulas,  ther» 
mometers,  and  other  infected  instruments  ;  (2)  for  the  thermometers  to  be  kept  in  ; 
(3)  for  the  sponging  of  those  dying  of  fever,  previous  to  their  removal  to  the  mor- 
tuary ;  (4)  diluted  -with  four  ti/nes  its  bulk  of  zuater,  for  the  daily  sponging  of  fever 
patients. 

Use  of  C. — For  the  disinfection  of  clothes  :  The  clothes  to  he  soaked  in  the 
solution  for  two  hours,  in  an  earthenware  vessel,  before  being  sent  to  the  wash. 

To  Disinfect  a  Room. — Tightly  close  all  windows,  fire-places,  and  ventila- 
tors. Moisten  powdered  sulphur  with  spirit,  place  it  in  a  shallow  iron  pan  sup- 
ported on  a  couple  of  bricks  in  a  bowl  of  water  ;  light  it,  and  keep  the  room  closed 
for  ten  hours.  Three  pounds  of  sulphur  must  be  used  for  each  1,000  cubic  feet  of 
airspace.  N.  B. — 5  lbs.  is  necessary  for  each  special  ward.  Then  open  all  win- 
dows, &c. ,  and  wash  the  floors,  walls,  furniture,  &c.,  with  the  following  solution  : 
Solution  C,iour  fluid  ounces  ;  water  one  gallon,  taking  especial  care  to  thoroughly 


864 


Diseases  of  Children 


wash  out  all   dust  from  window-ledges,  corners,  &c.     Allow  free  ventilation  for 
twenty-four  hours. 

LOEFFLER'S    D-BACILLUS. 

A  small  piece  of  membrane,  exudation,  or  mucus  is  broken  up  or  smeared  over 
a  covered  glass,  and  the  latter  dried  by  passing  it  several  times  through  the  flame  of 
a  spirit  lamp,  taking  care  not  to  overheat.  A  few  drops  of  a  solution  of  LoefHer's 
potash-mcthylene  blue  are  placed  on  the  dried  exudation  for  five  minutes  ;  the 
cover  glass  is  then  again  dried,  a  drop  of  balsam  placed  on  it ;  it  is  then  placed  on 
a  glass  slide  and  examined  with  a  -,-2  oil  immersion.  The  D-bacilli  may  usually  be 
recognised  by  the  characters  already  given  (p.  280).  It  must  be  admitted,  however, 
their  morphological  characters  are  often  not  decisive. 

Cultivations  on  blood-serum  and  injections  of  the  medium  used  for  cultivations 
into  guinea-pigs  may  be  necessary  in  some  cases  of  a  doubtful  nature.  ' 


Table  of  Average  Heights  and  Weights  Jrom  Birth  to  Fourteen  Years  (Rotch). 


Boys 

Girls 

Age 

Height 

Weight 

Height 

Weight 

inches 

lbs. 

inches 

lbs. 

I9"75 

7-15 

Birth 

19-28 

6-93 

24 '75 

14-30 

5  months 

23-25 

13-86 

29'53 

20-98 

I  year 

29-67 

19-8 

33-82 

30-36 

2  years 

32-94 

29-28 

37-06 

34-98 

3      ,, 

36-31 

33-15 

39'3r 

37-99 

4      ,, 

38-80 

36-56 

4i'37 

41 

5       ,, 

41-29 

39-57 

43-75 

45-07 

6      ,, 

43-35 

43-18 

45-74 

48-97 

7      ,, 

45  ■■52- 

47-30 

47-76 

53-81 

8      ,, 

47  58 

51-56 

49-69 

59 

9      .. 

49-37 

57 

51-68 

65-16 

10 

51-34 

62-23 

53-33 

70-04 

II 

53-42 

68-7 

55-11 

76-75 

12      ,, 

55-88 

78-16 

57-21 

84-67 

13      ,, 

58-16 

88-46 

59-83 

94-49 

.     14      w 

59-94 

98-23 

J\f_B. —  The  weights  during  first  three  years  are  without  clothes;  after  third  yea? 
in  ordinary  indoor  clothes. 


Appendix 


865 


FORMULA 


The  doses  given  are  su 

itahle 
3RD 

for  ati  inf 

int  of  a  year  old  unless  oih 

'rwise 

staled. 

DIS( 

ERS   OF 

DENTITION,    p.  63 

(I) 

(la) 

I'otassii  bromidi 

gr.  iiss 

Chloralis 

gf.  ij 

Tr.   hyoscyami 

.      TTl  V 

Potassii  bromidi 

gr.  ij 

Ext.  glycyrrh.  fl.      . 

■ni  X 

Sp.  ammon.  aromat. 

m  ij 

Aquee 

•    q- 

s.  ad  5  j 

Syrupi  pruni  Virg. 

TTl  X 

Every  two  or  three  hours 

Jor 

an  infant 

Aquse 

■    q- 

s.  ad  3  j 

of  seven  mon 

ths. 

Every  two  or  thr 

'e  hours. 

(2) 

(3) 

Hydrargyri  chlor.  mit. 

gr.  ss 

Sodii  boratis    . 

3ss 

Euonymin 

gr.  ss 

Tr.  myrrhfE     . 

3  ss 

Sacchari 

gr.  ss 

Glycerini 

3j 

The  powder  at 

night 

Aq.   rosse 

!j 

To  be  painted  on  the  gums  or  aphthous 
patches. 


CATARRHAL  STOMATITIS,  p.  65- 

(4) 


(4a) 


Potassii  chloratis 
Syrupi  aurantii 
Aquae      .         .         .         •     q- 
Three  times  a  day. 

(5) 
Acidi  borici     . 
Sp.  thymol 

(I-IO) 

Glycerini 

Aquae      .  .  .  •     q- 

To  be  painted  on  the  aphthous  patches. 


gr.  j 

Potassii  chloratis 

gr.  j 

Til  XV 

Ext.  cinchonse  fl. 

TTi  V 

ad3j 

Elixir  aromat. 

m  V 

Aquae 

.      q.  s 

ad3j 

Three 

times  a  day. 
(6) 

gr.  X 

vSodii  bicarb.   . 

. 

3j 

TTl  V 

Sp.  thymol 

3j 

Glycerini 

3ij 

3ss 

Aquae 

q.  s. 

ad  f  viii 

ad!j 

As  a  mouth-wash  for  child 

-en. 

(7) 


ACUTE   TONSILLITIS,  p.   74 


Tr.  aconiti       .  .  .  .      Tfl,  j 

Liq.  ammon.  citratis.      (Br.)    .       3j 
Syrupi  aurantii         .  .  .      HI  xx 

AquK      .  .         .         .     q.  s.  ad  3  ij 

Every  three  hours,  for  a  child  of  five 
years. 


(8) 


Sodii  salicylatis 
Potassii  citratis 
Syrupi  pruni  Virg. 
Aquae 

Every  tJiree  hours^  for  a  child  of  five 
or  six  years. 


■     gr.  V 
•     gr.  V 

.        Til,   XX 

q.  s.  ad  3  ij 


866 


Diseases  of  Children 


(9) 
lodi gr.   iij 

Potassii  iodidi         .         .         •      3  j 

Glycerini         .  .         .         q.  s.  ad  3  j 

Pigment  for  enlarged  tonsils. 


(10) 
Aluminis  .  .  .  .       3  ij 

Acidi  tannic!  .         .         .      3  ss 

Glycerini         .         .         .         .      §  ss 
Aquas  rosze     .         .         .       q.  s.  ad  § 
Pigment  for  enlarged  tonsils. 


FLATULENCE   AND  COLIC,  p.   84 

(II) 

(12) 

Magnesii  carb. 

gr.  iiss 

Chloralis 

gr.  iiss 

Rhei        .... 

gr.  i 

Aq.  laurocerasi.     (Br.) 

TTl  X 

Syrupi  zingiberis     . 

TIL  V 

Syrupi  pruni  Virg. 

TTlx 

Aq.  menth.  pip.       .          .     q. 

s.  ad  3  j 

Aquoe 

.     q.  s 

ad3j 

Every  two  hours,  for 'an  infant  three  or 

Every  three  hours. 

fozir  months  old. 

{Vil^ — TTl,j  of  nepenthe  may  be 

added  to 

each  dose  if  the  infant  is  under  close 

observation.) 

(13) 

(14) 

Sodii  bicarb. 

gr.  iiss 

Hydrargyri  cum  creta 

gr.\ 

Sp.  ammon.  fcetid.      (Br.) 

"HI  ij 

Pulv.  ipecac  et  opii 

gr.  i 

Sp.  chloroform! 

.       ITLj_ 

Sacchari 

gr.i 

Aquce  anethi.     (Br.)         .      q. 

s.  ad  3  j 

Ft.  pulv. 

Occasionally'. 

VOMITING,  p.  84 

(15) 

(16) 

Sodii  bicarb. 

gr.  iiss 

Liq.  bismuth  et  ammon 

.citr.(Br 

)TrL  V 

Aq.  laurocerasi.    (Br.) 

.     "ni  X 

Tr.  nucis  vomicae    . 

TTl  ss 

Sp.  chloroform! 

.    mj 

Glycerini 

TTL  X 

Aq.  anethi.     (Br.)  . 

.     ad  3  j 

Aq.  carui.      (Br.)     . 

ad3j 

Every  four  hours. 

Every  four 

hours. 

SIMPLE  DIARRHCEA,  p.   87 

•   (17) 

(18) 

01.   ricini         .... 

.       TTl,  XV 

Sodii  bicarb. 

gr.  ij 

Acaciae    .... 

•     gr.  V 

Bismuth,  subcarb.   . 

gr.  iss 

Syrupi  zingiberis     . 

.       TTl,  V 

Tragacanthoe 

gr.  j 

Aq.  menth.  pip. 

.     ad  3  j 

Sp.  chloroformi 

TTL  iiss 

Every  two  hours. 

Aq.  cinnamomi 

Every  four 

hours. 

ad3j 

(19) 

(20) 

Zinci  oxidi 

.     gr.  iss 

Acidi  nitrici  dil. 

. 

^] 

Tragacanthoe  . 

•     gr-  j 

Syrupi  auranti! 

TTL  X 

Sp.  chloroform! 

.      TTlj 

Decoct!  granat!  radicis. 

(Br.)    q 

s,  ad  3  j 

Glycerini 

.        Til,  XV 

Every  four 

hours. 

Aq.  anethi 

.     ad  3  j 

Every  four  hours. 

Appendix 


867 


(21) 

Acidi  nitro-hydrochlorici  dil. 

Tl  J 

Liq.  peptici 

. 

.        Ill   XX 

Sp.  chloroform i 

.      ifL  j 

Aq.  aurantii  flor. 

.     ad  3  j 

Three 

times  a  dav. 

(22) 


CONSTIPATION,  p.  8S 


Acidi  sulph.  aromat.         .         •      TU  j 
Magnesii  sulphatis  .         .         .      3  ss 
Ferri  sulphatis         .         .         .     <gx.  \ 
Sp.  chloroformi        .  .  .      TTl,  v 

Aquae      .         .         .         .       q.  s.  ad  §  ss 
Tivo  or  three  times  a  day  before  meals, 
for  a  child  of  ten  or  twelve  years. 

(24) 
Tr.  belladonnre         .  .  .      TTl,  v 

Tr.  nucis  vomicae     .         .         •     '^  \ 
Syrup,  sennce  .         .         .     ill  x 

Inf.  gentianre  co.     (Br.)  .         .     ad  3  j 

Three  times  a  day,  for  a  child  of  three 
or  four  years.      (Eustace  Smith.) 


(23) 


Podophylli       .         .         •  •     gr.  i 

Euonymin        .         .         .         •     gr-  i 
Ex.  cascara  sag.       .         .         •     gr.  j 

In  Palatinoids  (Oppenheimer)  one  or 
two  a  day,  for  a  child  of  six  to  twelve 
years. 


(25) 
Ex.  cascara  sag.  liq. 
Tr.  belladonn£e 
Elixir  aromat. 
Aquae 


At  bedtime. 


.       Til,  V 

.     ni  V 

.       Ill  X 

q.  s.  ad  3  j 


ACUTE   GASTRIC   CATARRH,  p.  90 


(26) 

(27) 

Acidi  hydrocyanici  dil.     . 

TU  j 

Sodii  bicarb gr.  x 

Sp.  chloroformi 

TTlj 

Aq.  laurocerasi.  "   (Br.)     .          .      TT[  xv 

Aq.  aurantii  flor. 

ad3j 

Aq.  aurantii  flor.      .          .          .       f  ss 

Every  three  hours. 

Acidi  citrici     .          .          .          .     gr.  v 
Aqu£e       .          .          .          .       q.  s.  ad  3  ij 
The  alkaline  and  acid  viixtiires  to  be 
taken  effervescing  every  four  hours,  for 
a  child  of  ten  or  twelve  years.     (Burney 
Yeo.) 

ZYMOTIC   DIARRHCEA,  p.  g6 


(28) 


(29) 


Sodii  salicylatis 

gr-  j 

Moschi    . 

01  ricini 

TTL  XV 

AcaciiH     . 

AcaciK    .... 

gr.  V 

Elixir  aromat. 

Syrup,  zingiberis 

TTl   V 

Aq.  rosie 

Aq.  menth.  pip.       .         .      q. 

s.  ad  3  j 

Ez 

Everv  tiuo  hours. 

q.  s 


Every  two  hours. 


gr.  i 
gr.  V 

TTl  V 

ad  3  j 


868  Diseases  of  Children 

(30)  (31) 

Bismuthi  salicylatis  .         .     gr.  j  Salol gr.  ij 

Sp.  ammon.  arom.  .         .      i^  ij  Pulv.  tragacanth.  co.     (Br.)     .     gr.  j 

Pulv.  tragacanth.  co.     (Br.)     .     gr.  j  Elixir  aromat.  .         .  .      IT^  v 

Sp.  chloroformi         .  .         .      tU  j  Aquoe       .         .         .         .     q.  s.  ad  3  j 

Aq.  carui.     (Br.)     .         .      q.  s.  ad  3  j  Every  two  hours. 

Every  three  hours. 

CHRONIC    DIARRHCEA,  p.  109 

(32)  (33) 

Extracti  hasmatoxyli         .         .  gr.  iiss  Argenti  nitratis        .         .         .     gr.  v 

Tr.  catechu      .  .  .  .  "ni  v  Aqua;       .  .  .  .  .      O  ss 

.Syrupi  tola       .  .  .  .  il  x  To  be  used  as  an  enema. 

Aq.  cinnamomi        .  .         .  ad  3  j 

Every  four  hours. 

CHRONIC    GASTRO-INTESTINAL    CATARRH,  p.  109 

(34)  (35) 

Sodii  bicarb gr.  ij  Sodii  bicarb gr-  i 

Pepsini gr.  j  Hydrargyri  cum  creta       .  •     gr-  i 

Sacchari  .         .         .         •     gr-  j  Pulv.  rhei  co.  ...     gr.  \ 

Half  an  hotir  after  meals.  Sacchari  .  .  .  •     gi"-  j 

Half  an  hour  after  meals. 

(36)  (37) 

Acidi  nitrici  dil.        .         .  .  "ni  iij  Acidi  hydrochlorici  dil.  .         .     "n^  iij 

Liq.  helaline  et  pepsin  co.  .  3  ss  Liq.  euonymin  et  peps.  co. 

Sp.  chloroformi        .         .  .  ttl  ij  (Oppenheimer)     .  .  .      3  ss 

Aq.  aurantii  flor.       .  .  .  3  iij  Elixir  aromat.  .  .  .      TlX  xv 

Three  .times  a  day.  Aquse       .  .  .  .      q.  s.  ad  3  ii] 

Three  times  a  day. 

{For  children  of  seven  to  ten  years.) 

(38)  (39) 

Sodii  bicarb.    .  .  .  .     gr.  v  Potassii  bicarbonatis 

Inf.  rhei.     (Br.)       .         .  •      3  j  Tr.  nucis  vomicae     . 

Elixir  aromat.  .         .         .      ni  xv  Aq.  laurocerasi.     (Br.) 

Aquffi       .  .  .  .      q.  s.  ad  3  iij  Elixir  aromat. 

Three  times  a  day  before  meals.  Aquae 

Three  times  a  day  before  meals. 

{For  children  of  seven  to  ten  years.) 

(40) 
Acidi  nitrici  dil.        .  .  .1^1  iij 

Ext.  cinchonce  fl.      .  .  .      Til  v 

Syrup,  aurantii         .         .         .      3  ss 
Aquae       .  .  .  .       q.  s.  ad  3  iij 

Three  times  a  day  after  meals,  for  children  of  seven  to  ten  years. 


gr.  V 

.      TIlj 

.       TTL  XV 

.     ni,  XV 

■    q- 

s.  ad  3  iij 

Appendix 


869 


TUBERCULAR   ULCERATION    OF    THE   BOWELS,  p.  148 

(41)  (42) 

Hydrargyri  cum  creta      .  .     gr.  j  Pulv.  kino  co.     (Br.)         .  .     gr.  i-iJ 

Pulv.  ipecac  et  opii  .  .     gr.  ij  Sacchari  .  .  .  .  •     gr.  ij 

Every  nigh/,  for  a  ciiild  of  five  years.         Every  night,  for  a  child  of  five  to  seven 

rears. 


(43)    ■ 
Emuls.  ol.  morriiua;  B.P.C. 

One  to  three  teaspoonfuls  thri 
day. 


times  a 


(45) 


(44) 
"  Bynol"  (Allen  &  Hanbury). 

One  to  three  teaspoonfuls  three  times  a 
day. 


Byno-hypophosphites  (Allen  &  Hanbury). 
One  to  three  teaspoonfzils  three  times  a  day. 

SCARLET  FEVER,  p.  264 


Potass,  chlorat. 

(46) 

•     gr.  V 

Amnion,  carb.     . 

(47) 

gr.  V 

Exti  cinchon.  fl. 

.      TTl  V 

Ex.  cinchon.  fl.  . 

TTl  V 

Elixir  aromat. 

.        TU  XV 

Tr.  digitalis 

TTl  V 

Aquoe     . 

q.  s.  ad   3  iij 

Syrup,  aurant.    . 

TTl  XX 

Every  four  hours,  for  a  child  of  five  to 

AquEe 

•    q- 

3.  ad  3  iij 

eight  years. 

Every  four  hour 

s,  for  a  child  of  five  to 

seveti  years. 
MEASLES,  p.  272 

(4S)                                                                      (49) 

Antimonii  et  potassii  tartrat.        gr.  -37.7 
Liq.  ammon.  acet.  .         .     Tl^,  xx 

Syrup,  tolu     .         .         .         .      tti,  xv 
Aquiis     .  .  .  .     q.  s.  ad    3  ij 

Every  four  hours,  for  a   child  of  five 
years. 


(50) 

Antipyrini      .         .         .  •  gr.  iii-v 

Sp.  chloroformi      .          .  .  1U  iij 

Elixir  aromat.         .         .  .  th,  x 

Aqute    .         .         .         .     q.  s.  ad   3  iij 
Every    six    hours,  for   a    child  of  six 
vears. 


Tr.  aconiti  .  .  •      ^l  j 

Liq.  ammon.  citrat.  (Br.)   .      TT^  xx 

Elixir  aromat.   .         .         .      tU  x 

Aquas         .  .  .      q.  s.  ad    3  ij 

Every  four  hours,  for  a  child  of  five  ■ 

years. 

INFLUENZA,  p.  293 

(51) 
Sodii  salicylat.  .         .     gr.  v 

Liq.  ammon.  acet.     .         .      3-SS 

Syrup,  tolu        .         .         .      3  ss 

Aquce         .  .  .     q.  s.  ad    3  iij 

Every  six  hours,  for  a  child  of  six  td  • 

eight  years. 


(52) 

Tr.  belladonnas    . 

1U  v-xv 

Extr.  cannabis  ind. 

•     gr.\ 

Glycerini 

.    m  XV 

Aquae  .          .         .         . 

q- 

s.  ad  3  ij 

WHOOPING  COUGH,  p.  316 


(53) 


Every  six  hotirs,  for  a  child  of  three  to 
five  years. 


Antipyrini  .  .  •     gr.  113 

Elixir  aromat.      .  .  .      Trj,  x 

Aqure  .  .  .      q.  s.  ad  3  ij 

Every  six  hours,  for  a  child  of  three  to  • 
five  years. 


870 


Diseases  of  Children 


(54) 

Pot.  bromidi         .         .  .  gr.  v 

Liq.  morphise  hyd.     (Br.)  .  v\  j 

Syrup.  scilifE         .  .  .  tq,  xx 

Aq.  aurant.  flor.  .  .  ad  3  ij 

£very  six   hours,  for  a  child  of  six  to 
eight  years. 


(55) 

Bromoform. 

Tzvo  or  three  drops  in  a  teaspoonful  of 

water  every  four  hours. 


CATARRHAL   LARYNGITIS,  P-   33© 


(56) 
Antimonii  et  potassii  tartatris       gr.  g-y 
Liq.  ammon.  citr.     (Br.)  .      TIL  x 

Elixir  aromat.  .         .         .      tq,  v 

Aquse      .         .         .         .     q.  s.  ad  3  j 
Eve7'y  four  hours,  for  a  child  of  two  to 
three  years. 


(57) 
Apomorphinse  hydrochlor. 
Vin.  ipecac 
Elixir  aromat. 
Aqu£e       .... 


•      ^  ij 

.      TTi  V 

q.  s.  ad  3  j 


Every  four  hours,  for  a  child  of  two  to 
three  years. 


BRONCHITIS  AND   BRONCHO-PNEUMONIA,  p.   362 


(58) 
Codeinse  ....     gr.  \ 

Elixir  rubrum  .  .         .      tti  v 

Aquse      .         .         .         .     q.  s.  ad  3  j 

Occasionally,  for  a  child  of  five  or  six 
years. 

(60) 

Ammon.  carb.  .  .  .  gr.  j 

Tr.  digitalis    .  .  .  .  TTl,  j 

Syrup,  scillifi  .         .         .         .  TTl,  xx 

Aq.  anethi.     (Br.)    .         .         .  ad  3  j 
Every  four  hours. 

(62) 
Tr.  capsici        .  .  .  .      §  ss 

Lin.  saponis    .         .         .         .      3  ss 
To  be  applied  to  the  affected  part. 

(64) 
Vini  ipecac.        .         .  .      1T[  ij 

Liq.  ammon.  citratis.  (Br.)  ttL  x 
Syrup,  tolu.  .  .  .  Tl[  x 
Aquae         .  .  .     q.  s.  ad  3  j 

Every  four  hours. 


(59) 

Liq.  morphinae  hydrochlor.  (Br.)  v\  ij 

Acid.  nitr.  dil.  .         .         .  ^) 

Syrup,  aurant,  .         .         .  TTj,  xx 

Aquae      .         .         .         .     q.  s.  ad  3  j 
Occasionally,   for  a  child  of  eight  to  ten 
years. 

(61) 
01.  sinapis  volat.     .         .         .      Tl],  x 
Lin.  camph.  .         .         •      1  j 

To  be  rubbed  on  the  afected part. 


(63) 
Capsici    .... 
Adipis  lanae  hydros.         .         •      o  j 
To  be  applied  to  the  affected  part. 

(65) 
Antimonii  et  potassii  tartrat.   . 
Liq.  morphias  hydrochlor.  (Br. 
Aq.  laurocerasi.     (Br.)    . 
Elixir  aromatici 
Aquae       .  .  .  .     q.  s.  ad  3  ij 

Every  four  hours,  for  a  child  of  five  to 
six  years. 


I  j 


gr.  2*0 
lUj. 

TTl  X 
TTl  X 


Appendix 


871 


(66) 


Potass,  bicarb. 

gr.  j 

Potass,  iodidi     . 

gr.  i 

Ext.  cinch,  il.    . 

TIL  ij 

Syrup,  sciila'     . 

m  X 

Aqure 

q.  s. 

ad  3  j 

Three  times 

a  dav. 

3  j 


(67) 
Sodii  bicarb.     . 

Glyc.  acid,  carbolici 

Aqux'        .  .  .  .       q.  s.  ad  I  j 

To  he  used  7vith  Siegle's  steam  spray. 

(Burney  Yeo.) 


ACUTE    PNEUMONIA,  p.  373 

(68)  (69) 


Liq.  strychnin;  . 
Tr.  digitalis 
Sp.  chloroformi 
Aq.  aurant.  flor. 


TTl  \ 

TiLij 
m  j 
ad  3  j 


Tr.  aconiti 
Liq.  ammon.  acet.    . 
Aq.  laurocerasi.     (Br.) 
Elix.  aromat.    . 


m  j 

111  XV 

iri  X 

TTl  X 


Every  four  hours,  for  a  eliild  oj  two  or 
four  years. 


Aquffi        .         .         .     q.  s.  ad  3  ij 

Every  four  hours,  for  a  child  of  two  to 
five  years. 


BRONCHIAL   ASTHMA,  p.  387 

(70)  (71) 

Pot.  iodidi          .  .  •     gr.  i\ 

Ext.  stramonii  .  .  •     gr.  tV 

Sp.  chlorof.       .  .  .      TTi  V 

Sp.  ammon.  aromat.  .      v\  v 

Aquns        .          .  .  q.  s.  ad  J  s 


gr-  20 
TTl  ij 
gr-  ij 
TTl  ij 


Antimonii  et  potassii  tartratis 
Liq.  morphict  hyd.     (Br.) 
Potass,  iodidi 
Sp.  chlor. 

AquDe      .         .  .         .     q.  s.  ad  3  ij 

With' an  equal  quantity  of  water  every 
three  hours,  for  a  child  of  five  or  six 
years.     (Burney  Yeo.) 


Three  times  a  day  (Burney  Yeo),  for  a 
child  of  ten  years. 


TUBERCULOSIS    OF    LUNGS,  P-  394 


(72) 
01.  morrhuK  .  .  .  .       3  ss 

Extr.  of  malt  .  .  .         .     ad  3  j 

Three  times  a  day. 

Lin.  iodi.      (Br.) 

Glycerini 

Aquae 


(74) 


(73) 
01.  morrhua;   .... 
Creasoti  ..... 
Three  times  a  day  after  food, 
nauseous.) 


3  j 
(  Very 


■      3ij 
s.  ad  3  iss 


(75) 


To  be  painted  over  the  affected  part. 
PERICARDITIS,  p.  416 


Pot.  bicarb.  .         .         •     gr-  x 

Tr.  aconiti  .  .  .  .  rri  ij 
Sp.  chloroformi  .  .  .  tti  v 
Aq.  aurant.  flor.  .     q.  s.  ad  |  ss 

Every  six  hours,  for  a  child  of  eight  to 
ten  years. 


(76) 


.Sodii  salicylat. 

•     gr.  X 

Liq.  ammon.  acet. 

.      3  ss 

Syrup,  aurant. 

3  ss 

AquiTs 

•  q- 

s.  ad   3  ss 

Every  six  hours,  for  a  child  of  eight  to 
ten  years. 


.Z'J2 


Diseases  of  Children 


CARDIAC 

TONICS,  p.  416 

ill) 

(7S) 

Tr.  ferri  chlor.     . 

.        Til  V 

Ferri  et  ammon.  citr.   . 

Tr.  digitalis 

.       TTl,  V 

Liq.  strychnice.     (Br.) 

Sp.  chloroformi    . 

.       Til  V 

Sp.  chloroformi    . 

Aquae 

q.  s.  ad  §  ss 

Glycerini      .         .         .         . 
Aquae            .          .          .       q. 

Three  times  a  day,  for 

a  child  of  eight  to 

Three  times  a  day,  for  a  chi 

twelve  ye 

ars. 

tivelve  years. 

gr.  V 

m  ij 

Til  V 

TTl  XV 

s.  ad  §  ss 
Id  of  eight  to 


DIURETICS    IN    CARDIAC    DROPSY,  p.  417 


(79) 


(80) 


Pot.  acetatis 

•     gr.  X 

Pot.  iodidi 

gr-  ij 

Succi  scoparii 

.      3  ss 

Tr.  sciilre     .... 

TTlv 

Tr.  digitalis 

.       TTl  V 

Tr.  strophanthi    . 

Tllv 

Sp.  chlor.     . 

.        Til   V 

Sp.  chlor.     .... 

TTlV 

Inf.  senegae.     (Br.) 

.      §ss 

Aquse            .          .          .      q.  s. 

ad  §  ss 

Three  times  a  day,  for  a  c 

hild of  eight  to 

Three  times  a  day,  for  a  child  of  eight  to 

twelve  years 

elevett  years. 

CARDIAC    STIMULANTS,  p.  417 

(81) 

(82) 

Sp.  Eetheris  co. 

.        TTl  X    , 

Liq.  strychniae.      (Br.) 

Ta  ij 

Tr.  nucis  vom. 

.        Til  V 

Ex.  cock;  fl.          .          .          . 

TTl  XV 

Tr.  lavandulne  co. 

.        TTl  X 

Sp.  chloroformi 

Til  V     -■ 

Aq.  carui.     (Br.) 

q.  s.  ad  1  ss 

Aq.  cinnamomi    . 

ad  1  ss 

Every  four  hours  or  a 

s  required. 

Every  four  hours. 

for  a  child  of  eight  to  t 

zvelve  years. 

for  a  child  of  eight  to  twelve  years. 

(Burney  Yeo 

.) 

(Burney  Yeo.) 

RHEUMATISM,  p.  460 

(83) 

(84) 

Sodii  salicylat. 

•     gr.  X 

Potass,  citratis     . 

gr.  X 

Pot.  bicarb. 

•     gr.  X 

Syrup,  limonis.     (Br.) 

3ss 

Syrup,  aurant. 

3  ss 

Aqu?s            .          .          .      q.  s. 

adgss 

Aquse 

q.  s.  ad  3  ss 

Every  four  ho2trs,  for  a  child  of  ten  years.     Every  four  hours,  for  a  child  of  ten  years. 
EPILEPSY    AND    CONVULSIONS,  pp.  531  and  536 


Potass,  bromid. 

■      gr-  vij 

Potass,  bromid. 

•          •      gr.  V 

Tr.  belladonna; 

.       TTl  X 

Sodii  bicarb.    . 

•     gr.  V 

Sp.  ammon.  aromat. 

.    in,  X 

Rhei 

.          ■     gr.  i 

Syrup,  aurant.  . 

.      3  ss 

Sp.  chloroformi 

.       TTl  V 

Aquae 

q.  s.  ad  1  ss 

Aqa£E       .          .          . 

q.  s.  ad  § 

Three  times  a  day,  for 

a  child  of  eight 

Three  times  a  day,  for 

a  child  of  eigi 

years. 

years. 

Appendix 


873 


(87) 

(88) 

Sodii  bromid.  . 

•     gr.  V 

Potass,  bromid. 

■     gr-  iij 

Elixir  cascara  sayrad. 

.       TTl  .X 

Syrup,  aiirant. 

.    m  X 

Sp.  ammon.  aromat. 

.     -ni  X 

Sp.  chloroformi 

.      n  j 

AquK       .... 

(].  s.  ad  3  ss 

Aquce 

q.  s.  ad  3  j 

Three  times  a  da\\  for  a  cJiild  of  eight       livery  two   hours,  for  an  infant  of  six 
years.  months. 


(Sg) 


(90) 


Potass,  bromid. 
diloral. 
SjTup.  aurant. 
Aqua> 


,     gr.  iiss  Chloral, 

gr.  iiss  Nepenthe 

TTL  XV  Elixir  aromat. 

q.  s.  ad  3  j  Aquse 


.  gr.  iiss 

.  mi 

.  TTL  V 

q.  s.  ad  3  j 


For  an  infant  of  a  year  old.  For  an  infant  of  a  year  old. 

NEPHRITIS^  pp.  265  and  607 

(91)  (92) 

Potass,  citratis  .  .  .     gr.  xv         Potass,  tart.     .  .  .  .     gr.  xv 

Syrupi  limonis.     (Br.)      .         .     TTl,  xx         Syrup,  aurant.  .         .         .      3  ss 

Aqua;       .  .  .  .      q.  s.  ad  5  ss       Aquse       .  .  .  .      q.  s.  ad  3  ss 

Fvery  four  hours,  for  a  child  of  six  to        Every  four  haters,  for  a  child  of  six  to 

ten  years. 


ten  years 

(93) 
Liq.  ammon.  acet.    . 
Tr.  digitalis 
Sp.  chlorof. 
Aqua^ 


(94) 


3  ss  Tr.  ferri  chlor. 

TTi,  V  Acid.  acet.  dil. 

Tr[  V  Liq.  ammon.  acet. 

q.  s.  ad  3  ss  Sp.  chlorof. 
Aquos 

Every  four  hours,  for  a  child  of  six  to  Every  four  hours,  for  a  child  of  six  to 
ten  years.  ten  years. 


.    m  V 

•      Tfl  ij 
3  ss 

.       TTL  V 

q.  s.  ad  §  ss 


ECZEMA  AND  IMPETIGO,  p.   784 

(95)  (96) 

Hydrarg.  chlor.  mit  .  •     gr.  i  Hydrarg.  c.  cret. 

Euonymin 
Sacchari  .... 


Every  other  ni^ 

(97) 
01.  inorrhure    . 
Liq.  potass,  arsenit. 
Mucilaginis  acacije  . 
Syrup,  aurant. 
Aqu;E 

Gut  teaspoonful  three  times  a  day  after 
food. 


gr.  i 
gr.  j 


Pulv.  rhei  co. 
Sacchari  . 


ght,  for  an  iiifant  of  six  months  old. 

(98) 
I  ij  Ichthyol .... 

3  j  Carron  oil         .  .  . 

q.  s.  To  be  applied  on  lint. 

I) 
q.  s.  ad  §  iv 


gr.  \ 
gr.  \ 
gr-  j 


Oss 


874 


Diseases  of  Children 


(99) 

(100) 

Calamin.Te  preparat.      (Br.) 

•      3ij 

Liq.  plumb,  subacetatis  . 

3  ss 

Zinci  oxidi 

.      3ss 

Tr.  opii  .... 

•      3ij 

Ol.  oliv 

•      !J 

AquK       .... 

q.  s.  ad  §  vj 

Liq.  calcis 

•      !J 

Ft.  lotio. 

(Crocker.) 

(lOl) 

(102) 

Acid,  boric.     . 

•      3j 

Zinci  oxidi 

.     gr.  XX 

Ol.  amygdalae  express 

.      3x 

Acid  carbolici 

•     gr-  X 

Cerae  alb. 

•      3j 

Oleum  rosas 

.      Tll^  ss 

Cetacei    .... 

•      3j 

Ung.  lanolini  .          .          . 

•       |ij 

Aq.  ros£e 

.      3x 

Ft.  ung. 

Ft.  ung. 

(103) 

(104) 

Acid,  salicylatis 

•     gr.  X 

Sulphur  precip. 

.     gr.  XX 

Zinci  oxidi 

•      3ij 

Lanolini .... 

3  ij 

Amyli       .... 

•      3ij 

Vaselini  .... 

It  ij 

Vaselini  .... 

.      !ss 

Zinci  oxidi 

3  ij 

Amyli      .... 

.      ^  ij 

(105) 

(106) 

Ung.  hydrarg.  ox.  flor.    . 

•       3j 

Ung.  hydrarg.  ox.  rubri  . 

•      3SS 

Five  per  cent.  ess.  vaselin 

s. 

Ung.  zinci  oxidi 

•      !J 

Cerati  petrolii 

•       oj 

(107) 

(108) 

(jlyc.  plumb,  acet. 

•      3ij 

Sulphur,  precip. 

.      3ss 

Liq.  carbonis  deterg. 

•      3ij 

Camphor. 

.     gr.  XV 

Aq.  rosas 

•      §vj 

Ung.  zinci  oxidi 

3  ii 

Amyli       .... 

.      3ii 

Cerati  petrolii 

•      31 

PSORIASIS,  p.  791 

(109) 

(I  to) 

01.  cadini 

.      3ss 

Chrysarobini 

•      3j 

Ung.  hydrarg.  ammon. 

•  ■    3ii 

Gutta-perchffi 

■      3j 

Ung 

•      3J 

Chloroformi 

3  X 

To  be  applied  to 

the  affected  parts. 

TINEA,  pp 

793  and   795 

(III) 

(112) 

Sulphur,  precip. 

3j 

Sod.  borat.    . 

•      3j 

Hydrarg.  ammoniati  . 

3ss 

Spir.  camph. 

•      3j 

Thymol      .... 

gr.  X 

Glycerini 

•      3ij 

Vaselini      .... 

3j 

Aq.  aurant.  flor. 

q.  s.  ad  §  iv 

Ung 

ad  giv 

T'o  be  Jised  as  a   /'lair-zaas/i. 

Appendix 


875 


(113) 

(114) 

Tr.  canUiarides 

3ij 

Tr.  cantharid. 

1  ss 

Tr.  capsici 

3ij 

Tr.  capsici 

Iss 

Tr.  nucis  voniiciv; 

3SS 

01.  ricini   . 

0  ss 

01.  ricini    . 

3ij 

Alcohol 

5iv 

Eau  de  Colosifne 

ad  3 

iv 

To  be   used  as  a 

hai) 

-wash. 

To  he  used  as  a 

hail 

-liHIsh. 

(115) 


SCABIES,  p.   796 


(116) 


Sulphuris  . 
Balsam  Peru 
Ung.  siniplicis  . 

3j 
3  ss 

Styracis     . 
Ung.  simplicis  . 

Naphthol 
Ung.  simplicis 

(117) 

3j 

3ss 
5  iss 


INDEX 


Abc£s  peribronchique,  360 
Abdomen,  examination  of,  82 
Abdominal  abscess,  124 
Abdominal  pain  in  spinal  disease,  719 

—  injuries,  8ci 

—  section  in  intussusception,  140 

—  wall,  hiatus  of,  155 
Abortive  pneumonia,  369 
Abscess,  acute  glandular,  239 

—  alveolar,  68,  655 

—  cerebral,  498,  760,  762 

—  chronic,  244,  841 

—  glandular,  244 

—  hepatic,  190 

—  iliac,  127 

—  in  bone,  654,  841 

—  in  hip  disease.  694,  84.1 

—  of  the  liver,  190 

—  of  the  lung,  375 

—  mediastinal,  389 

—  parosteal,  637 

—  pelvic,  695 

—  periarticular,  693 

—  perioesophageal,  78,  80 

—  periglandular,  240 

—  periosteal,  637 

—  perisigmoid,  126,  127 

—  peritonea],  120-127 

—  perityphlitic,  122-124,  127 

—  post-pharyngeal,  78 

—  psoas,  697,  698,  715,    724 

—  residual,  701,  706 

—  retro-cesophageal,  78 

—  sacral,  726 

—  spinal,  715,  717 
Absence  of  mouth,  177 

—  of  tongue,  175 
Accidental  idiocy,  556 
Accidents  with  anaesthetics,  824 
A.  C.  E.  mixture.  820 
Acetabular  disease,  688  et  seq. 
Acetabulum,  '  travelling,'  689 
Acquired  clubfoot,  727 

—  hernia,  156 

—  syphilis,  446 

—  talipes,  727 


Acromio-clavicular  joint,  disease  of,  685 
Acute  adenitis,  239,  240 

—  atrophic  paralysis,  578 

—  bronchitis,  351 

—  cerebral  congestion,  247 
paralysis,  504 

—  circumscribed  osteomyelitis,  645 

—  epiphysitis,  646 

—  gascro-intestinal  catarrh,  90 

—  generalised  broncho-pneumonia,  360 

—  glandular  abscess,  239 

—  iiip-disease,  690,  844 

—  meningitis,  447 

—  miliary  tuberculosis,  232 

—  necrosis,  637 

—  nephritis,  603 

—  orchitis,  318,  628,  630,  631 

—  osteomyelitis,  645 

—  periostitis,  636  et  seq.,  637 

—  peritonitis.  118 

—  rickets,  200 

—  simple  serous  synovitis,  667 

—  suppurative  arthritis  of  infants,  670 

—  tonsillitis,  70 

—  tuberculous  synovitis,  672 

—  yellow  atrophy  of  liver,  184 
Acutely  inflamed  tonsils,  removal  of,  76 
Addison's  disease,  607 

Adenitis,  acute,  239,  240 

—  tuberculous,  237 
Adenoids,  post-nasal,  77 
Adenomata  recti,  163 
Adjacent  abscess,  693 
Adolescence,  rickets  of,  216 

—  synovitis  of,  710 
Adrenals,  disease  of,  607 

Ace  for  operation  in  hare-lip,  168 
Air-passages,  foreign  bodies  in,  346 
Albuminuria  in  healthy  children,  594 

—  in  diphtheria,  284 
Alimentary  canal,  6 
Alopecia  areata,  796 

Alum  in  whooping-cough,  316 
Alveolar  abscess,  68,  655 
Amputation  at  hip-joint,  711 

—  intra-uterine,  744 


878 


Inde:\ 


Amputation,  primary,  812 
Amiissat's  operation,  152 
Antemia,  432 

—  idiopathic,  434 

—  lymphatica,  439 

—  pernicious,  434 

—  splenic,  437 

—  with  oedema.  433 
Anaesthetics,   816 
Anal  condylomata,  163 

—  fissures,  164 

—  fistula,  163 

Anastomosis,  aneurism  by,  428 
Anchyloglossus,  175 
Aneurism,   430 

—  by  anastomosis,  428 

—  of  middle  cerebral  artery,  431,  514 
Angina  Ludovici.  245 

Angioma,  cavernous,  422 

—  lymphatic,  42S,  767 

—  simple,  421 

Angular  curvature  of  spine,  713,  847 
Ankle,  excision  of,  681 

—  tubercular  diseases  of,  666 
Ankylosis  of  jaw,  6S5 
Anterior  polio-myelitis,  578 
Antipyretics,  854 
Antitoxin,  287 

Anus,  artificial,  15J 

—  imperforate,  150 

—  ulceration  of,  164 
Aortic  regurgitation,  413 
Aphasia,  550 
Aphthous  stomatitis,  64 

—  vulvitis,  625 
Apoplexia  neonatorum,  19 
Appendicular  peritonitis,  122 
Appendix,  intussusception  of,  142 

—  removal  of,  127 
Arm,  fractures  of,  811 

Arrest  of  growth  after  epiphysitis,  644 

in  rickets,  209,  216 

after  injury,  803,  807,  808 

Arterial  nsevus,  421 
Arterio-venous  varix,  427,  428 
Arteritis,  33 
Arthrectomy,  676  et  seq. 
Arthritis  deformans,  461 

—  with  glandular  enlargement,  462 

—  of  infants,  acute  suppurative,  670 

—  rheumatic,  461,  669 
Arthrodesis,  736 

Artificial  muscle,  733,  737,  740,  849 
Ascaris,  115 
Ascites,  116 

—  in  cirrhosis,  186 
Asphyxia  neonatorum,  17 


Aspiration  for  empyema,  381 
Asthma,   386 
Asymmetry,  851 
Athetosis,  504,  508,  556 
Athrepsia,  103 
Atlanto-axial  disease,  713 
Atresia  ani,  150 

—  oris,  177 
Atrophy  of  brain,  489 

—  of  face.  177,  742 

—  gastro-intestinal,    103 

—  of  jaw,  685 

—  of  liver,  acute  yellow,  184 

—  muscular,  590 

—  progressive  muscular,  586 

—  simple,  103 
Auricle,  disease  of,  758 

—  supernumerary,  178 
Auscultation,  322 

Axis  traction  for  hip-disease,  704, 


Bacillus,  Gaertner's,  loi 

Backward  children,  557 

Balanitis,  624 

Barley  water,  51,  852 

Barwell's  artificial  muscle,  733,  737,  740 

Basal  ganglia,  tumours  of,  496 

Belladonna  in  whooping-cough,  317 

Biedert's  cream  mixture,  48 

Bifid  anus,  150 

—  tongue,   176 

—  uvula,   167 

Bile-ducts,  stricture  of,  182,  183 

—  secretion  of,  7 
Birth,  circulation  after,  4 

—  diseases  incident  to,  17 

—  marks,  421 

—  palsy,  502 
Bladder,  calculus  of,  609 

—  extroversion  of,  617 

—  inflammation   of,  613 

—  rugous,  613 

—  tuberculous  disease  of,  613 

—  tumours  of,  613 
Bleeders,  28,  34,  440 
Bleeding,  814 

—  after  excision  of  tonsils,  76 
Blennorrhagia,  32 

Blood,  amount  in  body,  5 

—  of  infant,  5 
Body-weight,  lO 
Bone  grafting,  802 
Bones,  diseases  of,  636,  841 

—  syphilitic  disease  of,   452,   454,   649, 

659 
Boric  acid  in  diphtheria,  28S 


Index 


<S79 


Howels,  chronic  obstruction  of,  T42 

—  congenital  obstruction  of,  14S 

—  tuberculous  ulceration  of,  144 
Bou'-leg,  213,  S36 

Brain,  abscess  of,  760,  762 

—  atrophy  of,  489 

—  congestion  of,  247,  468 

—  cyst  of,  491 

—  development  of,  8 

—  hypertrophy  of,  489 

—  sarcoma  of,  491 

—  sclerosis  of,  488 

—  softening  of,  484,  573 

—  surgery  of,  498,  760,  762 

—  syphilis  of,  454,  482 

—  tumours  of,  491 

—  weight  of,  8 
Branchial  cartilages,  178 

—  dermoid  cysts,  180 

—  fistulre,  178 

median,  179 

Bromide  rash,  792 

Bronchial  glands,  adenoma  of,  390 

—  diseases  of,  387 
Bronchiectasis.  353 
Bronchitis,  351 

—  acute,  351,  360 

—  chronic,  354 
Bronchocele,  777 
Broncho-pneumonia,  355 

—  in  measles,  270 

—  acute  generalised,  360 

—  chronic,  358 

—  disseminated,  360 

—  microorganisms  in,  361 

—  from  tuberculosis,  233 
Bryant's  splint,  702,  708 
Burns  and  scalds,  813 
Bursa  of  Fleischmann,  177 
Bursse  in  club-foot,  743 
Bursitis,  743    • 


CtECAL  colotomy,  153 

—  hernia,  157 

Calcaneo-astragaloid  disease,  683 
Calculus  of  kidney,  602 

—  in  tonsils,  76 

—  urethral,  610,  614 

—  vesicse,  609 
Callisen's  operation,  152 
Calomel  fumigation,  336 
Calot's  operation,  825 
Canal  of   His,  179 
Cancrum  oris,  69 
Capillary  nsevus,  421 
Caput  succedaneunij  23 


Carbolic  acid  in  whooping-cough,  317 
Carcinoma  of  stomach,  113 
Cardiac  dilatation,  414 
in  nephritis,  260 

—  murmurs,  413 

—  syncope  in  diphtheria,  285 
Carditis,  acute,  404 

Caries,  636 

—  of  spine,  713,  847 

Carpo  ]3edal  contractions,  534 
Cartilages,  branchial,  178 
Cartilaginous  tumours,  765,  766 
Caseation  of  bronchial  glands,  387 

—  of  lung,  390 
Catarrh,  acute  gastric,  90 
gastro-intestinal,  90 

—  of  bronchial  tubes,  351 

—  chronic  gastro-intestinal,  103 
Catarrhal  jaundice,  183 

—  laryngitis,  329 

—  synovitis,  668 

—  tonsillitis,  acute,  70 
Caudal  appendage,  570 
Cavernous  angioma,  422,  767 

—  naevus,  422 

—  sinus,  thrombosis  of,  763 
Cellulitis,  deep  cervical,  245 
Cephalhasmatoma,  21 
Cephalhydrocele,  800 
Cerebellar  abscess,  498,  760,  762 
Cerebellum,  tumours  of,  493 
Cerebral  abscess,  498,  760,  762 

—  cyst,  491 

—  hsemorrhage,  501,  504 

—  lesions,    surgical   treatment   of,    499, 
760 

—  paralysis,  acute,  504 

—  pneumonia,  370 

—  sinuses,  thrombosis  of,  514 

—  softening,  484,  513 

—  tumour,  491 

—  congestion,  247,  468 
Cerehro-spinal  meningitis,  480 
Cervical  cellulitis,  70,  245 

—  paraplegia,  720 
Chest,  examination  of,  321 

—  form  of,  in  infancy,  321,  835 

—  injuries  of,  8or 

Cheyne  Stokes  respiration,  471 
Chilblains,  789 
Child-crowing,  323 
Childhood,  2 
Chloroform,  821 
Chlorosis,  432 
Cholera  infantum,  90 
Chorea,  515 

—  insaniens,  522 


88o 


Index 


Chorea,  paresis  in,  521 

—  peripheral  neuritis,  521 
Choroid,  tubercles  of,  233 
Chronic  bronchitis,  354 

—  broncho-pneumonia,  35S 

—  circumscribed  osteomyelitis,  652 

—  diarrhoea,  105 

—  diffuse  osteomyelitis,  654 

—  gastro-intestinal  catarrh,  103 

—  hydrocephalus.  485 

—  intussusception,  131 

—  laryngitis,  348 

—  nephritis,  605 

—  obstruction  of  bowels,  142 

—  periostitis,  648 

—  peritoneal  efTusion,  117.  128 

—  peritonitis,  117,  128 

—  rheumatic  arthritis,  461,  669 

—  tonsillar  hypertrophy,  74,  330 

—  tonsillitis,  74 

—  vomiting,  105 

Circulation,  changes  in,  after  birth,  4 

Circumcision,  623 

Cirrhosis  of  liver,  186 

Classification     of    bone    inflammation, 

645 
Clavicle,  deficiency  of,  752 

—  fractures  of,  8 10 
Clavus  hystericus,  468 
Cleft  of  lower  lip,  174 

—  of  palate,  171 
Clothing  of  infants,  39 
Club-foot,  727,.  848 
Club-hand,  747,  851 
Club-leg,  740 
Coccygeal  dimple,  569 
Colic.  84 

Collapse  of  lung,  353 
Colon,  dilatation  of,  142 
Colotomy,  inguinal,  152 

—  lumbar,  152 

Coma  in  meningitis,  471 
Compound  congenital  tumours,  772 
Compression  of  trachea,  329 
Condensing  osteomyelitis,  656 

—  ostitis,  637 
Condyloma  of  tongue,  177 
Condylomata,  177,  452 
Congenital  deficiency  of  muscles,  743 

—  deformities  of  digestive  tract,  177 
of  oesophagus,  180 

—  dislocation  of  hip,  751,  851 

—  heart-disease,  397 

—  hernia,  156 

—  hydrocele,  633 

—  hypertrophy  of  oesophageal  glands,  81 

—  idiocy,  552 


Congenital  laryngeal  stridor,  322 

—  mucoid  cyst  of  tonsil,  74 

—  nsevus,  421 

—  obstruction  of  bowels,  148 

—  rickets,  203 

—  sacral  fistula,  569 
tumours,  772 

—  stricture  of  bile-ducts,  182 
of  oesophagus,  180 

—  syphilis,  477 

— ■  syphilitic  periostitis,   452,    454,    649, 

659 

—  tuberculosis,  228 

—  tumours,  772 

—  urethral  anus,  150 
Constipation,  88 
Constriction  of  limbs,  746 
Contraction   of    meatus    urinarius,   616, 

621 
Convulsions,  532 
Cord,  separation  of,  31 
Cortical  layer,  tumours  of,  496 
Coryza,  syphilitic.  448,  453 
Costo-vertebral  disease,  726 
Coxalgia,  687 
Coxa  vara,  211,  710 
Craniectomy,  559 
Craniotabes,  200 
Cream  mixture,  48 
Creeping  pneumonia,  370 
Cretinism,  559 

Croton  chloral  in  whooping-cough,  317 
Croup,  diphtheritic,  332 

—  membranous,  332 

—  spasmodic,  327 
Croupous  angina,  290 

—  exudation  on  navel,  32 

—  pneumonia,  366 
Cryptorchism,  627 

Curvature  of  spine,  angular,  713,  847 

lateral,  225,  837 

rickety,  210,  835 

—  of  tibia,  213  et  seq.,  836 
Cutaneous  nsevus,  422 
Cyanosis,  398 

Cystic  disease  of  testis,  633 

—  growth  of  vulva,  627 

—  lymphangioma,  428,  767 

—  tumours,  767  et  seq. 
Cystinuria,  594 
Cystitis,  613 

—  tubercular,  613 

Cysts,  dermoid,  164,  177,  180,  571,  635, 
768  et  seq. 

—  of  jaws,  776 

—  serous,  7^7 

—  sublingual,  176,  767 


Index 


88 1 


Dactylitis,  syphilitic,  659 

—  tuberculous,  657 
Deaf-mutism,  547 
Deafness,  759 

Deep  cervical  cellulitis,  245 
Deformities  of  (lesophagus,  180 

—  in  rickets,  208,  835 

treatment  of,  21S,  836 

rickets,  operations,  220 

—  of  umbilicus,  154 

Deformity  from  thumb-sucking,  177 
Degenerated  neevus,  423,  428 
Degeneration,  reaction  of,  581 
Dental  formulae,  13 
Dentigerous  cysts,  776 
Dentition,  ailments  of,  60 
-^  course  of,  12 

—  second,  63 
Depressed  scars,  243 
Derbyshire  neck,  777 
Dermatitis  gangrenosa,  792 

—  exfoliata,  792 

Dermoid  cysts,  164,  177,  180,  571,  635, 
768,  769  et  seq. 

branchial,  17S 

of  rectum,  164 

Developmental  idiocy,  556 
Deviation  of  nasal  septum,  755 
Diabetes  insipidus,  464 

—  mellitus,  463 
Diaphragmatic  hernia,  154,  160 
Diarrhoea,  86 

—  chronic,  105 

—  dysenteric,  99 

—  lienteric,  87 

—  in  measles,  271 

—  summer,  90 

—  zymotic,  90 

Diet  of  infants,  56,  57,  828 

—  tables  for  indigestion,  iii 
Digestive  system,  diseases  of,  60 
Digitalis  in  heart-disease,  417 
Dilatation  of  the  ventricles,  414 

—  of  stomach,  112 

—  of  colon,  142 
Dilator,  tracheal,  340 
Diphtheria,  27S,  332,  371 

—  antitoxin,  287 

—  diagnosis  of,  286 

—  pathology  of,  279 

—  treatment  of,  287 

—  albuminuria  of,  284 

—  cardiac  syncope  in,  285 

—  epidemics  of,  279 

—  infectious  nature  of,  279 

—  laryngeal,  284,  332 
- — •  malignant,  283 

:;6 


Diphtheria,  mild,  282 

—  paralysis  in,  285 

—  pharyngeal,  281 

—  pneumonia  in,  285 

—  quarantine  in,  289 

—  bacillus  of,  2S0 

—  nasal,  283 

—  prognosis  in,  286 

—  pseudo,  290 

—  rashes  in,  283 

—  wound,  284 
Diphtheritic  croup,  332 

—  infection  of  navel,  32 

—  paralysis,  285 

—  sore  throat,  290 

Direct  tubercular  infection,  145,  228 
Dislocations,  696,  750,  812 
Dislocation  of  elbow,  812  1 

—  of  hip,  696,  812 
congenital,  751,  851 

—  of  patella,  813 

—  of  shoulder,  812 

congenital,  751 

Displaced  nasal  septum,  755 
Disseminated  broncho-pneumonia,  360 

—  myelitis,  575 

Distribution  of  lymphatic  glands,  237 
Diverticula  of  oesophagus,  79 
Diverticulum,  Meckel's,  31,  155 
Double  monsters,  745 

—  hip  disease,  712 

—  hip  splint  for  spinal  caries,  722,  723 

—  urethra,  622 
Dressings,  Si 5 

'  Dry  bellyache,'  719 
Duck-toes,  740 
Ductus  arteriosus,  4 
obliteration  of,  4 

—  venosus,  4 

Dyspeptic  diseases  of  infancy,  83 
Dyspnoea  from  spinal  abscess,  329 
Dysenteric  diarrhoea,  99 
Dysphagia  in  spinal  disease,  718 


Ear,  closure  of  meatus  of,  758 

—  diseases  of,  475,  477,  498,  758 

—  foreign  body  in  the,  758 
Early  Ijfe,  periods  of,  i 
Eclampsia,  532 

Ectopia  vesicce,  617 

Eczema,  780 

Elbow,  disease  of,  664,  843 

—  dislocation  of,  812 
Embolism,  431,  511 

—  in  nephritis,  260 

—  tubercular,  229 


Index 


Emphysema,  353 

—  in  tracheotomy,  341 

—  vicarious,  360 
Empyema,  375 

—  from  necrosis  of  rib,  643 

—  surgical  treatment  of,  381 
Encephalocele,  570 
Enchondroma,  765,  773  et  seq. 
Encysted  hernia,  156 
Endarteritis,  484. 
Endocarditis,  407 
Enlarged  spleen,  436,  453 
Enteric  fever,  293 

abdominal  symptoms  in,  2g6 

bronchitis  and  pneumonia  in,  2c 

contagious  nature  of,  294 

diagnosis  of,  360 

epistaxis  in,  297 

hsemorrhage  in,  297 

incubation  of,  294 

membranous  tonsillitis  in,  299 

mortality  of,  294 

perforation  of  intestine  in,  298 

peritonitis  in,  298 

pyemia  in,  298 

rash  in,  296 

relapses  in,  297 

symptoms  of,  295 

temperature  of,  295 

treatment  of,  361 

tuberculosis  in,  299 

Enucleation  of  tonsil,  76 
Enuresis,  614 
Epidemic  influenza,  290 

—  tonsillitis,  72 
Epilepsy,  526 

—  trephining  for,  531 

—  post-hemiplegic,  529 
Epiphyses,  separation  of,  803 

—  dates  of  union  of,  810 
Epiphysitis,  636  et  seq. 

—  syphilitic,  454-456 
Epispadias,  620 
Epistaxis,  757 
Epithelioma  of  kidney,  597 
Erasion,  676 

—  of  ankle,  6S0 
Eruptions,  drug,  792 
Erysipelas,  310,  639,  815 
Erythema,  310,  788 

—  multiforme,  459,  788 

—  nodosum,  460,  789 

—  pernio,  789 

—  scarlatiniforme,  788 
Estlander's  operation,  385 
Ether,  S21 
Examination  of  chest,  321 


Exanthematous  periostitis,  649 

—  synovitis,  256,  660,  668 
Excision,  677 

—  of  ankle,  681,  736 

—  of  hip,  704,  847 

—  of  knee,  677,  736 

—  of  tarsus,  682 
for  club-foot,  735 

—  of  wrist,  843 
Excoriation  of  navel,  32 
Exostosis,  767 
Expectorants,  859 

Extension  for  hip  disease,  702,  844 
External  meatus  of  ear,  closure  of,  758 
Extravasation  of  urine,  610,  617,  801 
Extroversion  of  bladder,  619 
Eyes,  syphilitic  affection  of,  454 


Face,  atrophy  of.  177,  742 

—  hypertrophy  of,  177 
Facial  paralysis,  761 
Frecal  fistula,  123,  125,  152 
False  croup,  326 

—  hydrocephalus,  94,  474 
— ■  spina  bifida,  568 
Fasting  girls,  540 

Fat  diarrhoea,  87 

Fatty  degeneration,  acute,  29 

—  liver,  189 

—  tumours,  770 
Favus,  796 

Feeble  vitality  in  hare-lip  cases,  167,  168 
Feeding,  artificial,  44,  828   - 
■ — •  bottles,  56 

—  of  infants  at  the  breast,  39 
Femora]  hernia,  160 
Femur,  fractures  of,  811 

Fever,  infantile  intermittent,  300,  319 

Feverishness  as  a  symptom,  246 

Fevers,  246 

Fibrocellular  tumour  of  tongue,  77 

Fibrous  tumours,  767 

Fingers,  contraction  of,  749 

Fissures  of  the  anus,  164 

—  of  mouth  in  syphilis,  449  et  seq. 

—  of  sternum,  752 
Fistula,  in  ano,  163 

—  branchial,  178 

—  intestinal,  123,  125,  152 

—  tracheal,  180 

—  umbilical,  124 
Fits,  hysteroid,  528 
Flat-foot,  738,  849 

—  in  genu  valgum,  215,  216 
Flatulence,  84 
Flea-bites,  797 


Index 


Foetal  pericarditis,  403 

—  peritonitis,  149,  150 

—  rickets,  203 

Foetus,  parasitic,  772,  774 

Fontanelies,  closure  of,  S 

Foramen  ovale,  patent,  398 

Forcible  straiijhtening  of  limbs,  220,  836 

Foreign  bodies  in  the  air-passages,  346 

in  ear,  75S 

—  —  in  nose,  754 

in  oesophagus,  80 

Fracture  after  necrosis,  645 
Fractured  base  of  skull.  801 
Fractures,  green-stick,  802,  837 

—  of  long  bones,  8ro 

—  of  pelvis,  Soi 

—  of  skull,  800,  801 

—  ununited.  645,  802 
Friedrich's  disease,  577 
PVontal  lobe,  tumours  of,  497 
'  Fungus  of  the  navel,'  31 
Funicular  hernia,  156 


Gangrene  of  the  lung,  374 

—  of  the  navel,  32 
Gastric  catarrh,  90 

—  juice,  6 

—  pneumonia,  370 

—  ulcer,  114 
Gastro-intestinal  atrophy,  103 

catarrh,  acute,  90 

chronic,  103 

—  enteritis,  go  et  seq. 

haemorrhage,  30 

Gastrostomy,  80 

General  purulent  peritonitis,  ir8  el  seq. 

—  surgical  tuberculosis,  243 

—  tuberculosis,  234 

Genital  organs^  heemorrhage  from,  30 
Genito-urinary  diseases,  592 

—  organs,  malformation  of,  617 
Genu  extrorsum,  213 

—  recurvatum,  749,  850 

—  valgum,  211  et  seq.,  836 

degree  of,  to  measure,  217 

from  rickets,  appearance  of,  211, 

836 

—  varum,  213 
Giant-foot.  429,  771 
Girdle-pain,  719 
Gland  fever,  247 

Glands   of  groin,  enlargement  of,  692, 
693,  699 

—  lymphatic,  distribution  of.  237 

—  retroperitoneal,  disease  of,  444 

—  bronchial,  disease  of,  387 


Glands,  mesenteric,  disease  of,  144 

Glandular  abscess,  acute,  239,  240,  245 

Glottis,  scald  of,  345 

—  sijasm  of  the,  323,  328 

Goitre,  777 

Gonorrhoea,  37 

Gonorrhoeal  rheumatism,  670 

'  Graines  jaunes,'  360 

'  Grand  mal,'  527 

Green-stick  fractures,  204,  802 

Growing  fever,  648 

Growth,  arrest  of,   210,  214,   216,  644, 

803  et  seq.,  851 
Gumma,  scrofulous,  241 


H^MARTHROSIS,   44I 

Hematoma  of  sterno-mastoid,  24,  740 

—  occipital,  25 
Hematuria,  593 
Haemoglobliinuria,  420,  593 

—  intermittent,  420,  594 
Haemophilia,  28,  440,  593 
Haemorrhage,  814 

—  cerebral,  501,  504 

—  gastro-intestinal,  30 

—  genital  organs,  30 

—  medullary,  510 

—  meningeal,  315,  502 

—  newly  born,  21 

—  umbilical,  34 

Hemorrhagic  diathesis,  28,  440,  593 
Hemorrhoids,  163 
Hallux  flexus,  750 

—  valgus,  750 
Hammer-toe,  750 
Hare-lip,  165 

—  cases,  feeble  vitality  in,  167 

—  median,  174 

—  operations,  age  for,  168 
Harvest  bug,  797 
Headache,  543 

Head,  cold  in  the,  754 

—  ir\juries,  800 
Head-banging.  540 

—  nodding,  539 

—  shaking,  539 

Hearing  in  the  newly  born,  9 
Heart,  diseases  of,  396 

—  dilatation  of,  414 
Heart-disease,  chronic,  410 

—  congenital,  397 

—  treatment  of,  445 
Hemichorea,  517,  522 
Hemiplegia,  505  el  seq. 

—  from  aneurism,  514 

—  causes  of,  505  el  seq. 


884 


Index 


Hemiplegia  from  meningitis,  472 
Hepatic  abscess,  igo 
Hepatitis,  interstitial,  188 

—  syphilitic,  188,  453 
Hepatomphalos,  154 
Hereditary  ataxic  paraplegia,  577 

—  syphilis,  447 
Hermaphrodites,  620 
Hernia,  acquired,  156 

—  of  cECCum,  157 

—  cerebri,  501 

—  congenital,  156 

—  diaphragmatic,  154,  160 

—  encysted,  156 

—  femoral,  160 

—  funicular,  156 

—  infantile,  156 

—  inguinal,   156 

—  of  liver,  154 

—  of  the  ovary,  157,  631 

—  radical  cure  of,  159 

—  rectal,  161 

—  strangulated,  157 

—  translucency  of,  157 

—  umbilical,   155 

—  and  undescended  testis,  628 

—  ventral,  155 

Herpes  zoster  in  spinal  disease,  71c 
Hiatus  vesicae,  617 

—  of  abdominal  wall,  155 
Hip  disease,  687,  845 
acute,  690 

congenital,  751,  851 

double,  712 

—  dislocation  of,  6g6,  751,  812 

—  excision  of,  704,  847 

—  reflex  muscular  spasm,  845 

—  results,  846 
His,  canal  of,  179 
Hodgkin's  disease,  439,  775 
Hollow  claw-foot,  729 

—  club-foot,  729 
Horse-shoe  kidney,   596 
Hydatids  of  the  liver,  igo 
Hydrencephalocele,  570 
Hydrocele,  159,  633 

—  of  the  neck,  176,  428,  774 
Hydrocephalic  cry,  470 
Hydrocephalus,  acute,  480,  485 

—  chronic,  485 

—  false,  94,  474 

—  and  spina  bifida,  569 
Hydronephrosis,  601 
Hygroma,  176,  428,  774 
Hymen,  imperforate,  625 
Hyperpyrexia  in  pneumonia,  370 
Hypertrophy  of  brain,  489 


Hypertrophy  of  face,  177 

—  of  labia,  625 

—  of  tonsils,  74 
Hypospadias,  620 
Hysteria,  540 
Hysterical  chorea,  522 

—  joints,  685 

—  vomiting,  85,  542 
Hysteroid  fits,  528 


Icterus  neonatorum,  26 

Idiocy,  551 

■ —  congential,  552 

—  cretinoid,  559 

—  developmental,  556 

—  eclampsic,  555 

—  epileptic,  555 

• — •  microcephalic.  554 

—  mongolian,  554 

—  syphilitic,  557 
Idiopathic  anaemia,  434 
Ileo-umbilical  diverticulum,  31,  155 
Ileo-colitis,  acute,  99 

Iliac  abscess,  127 
Imitation  in  chorea,  516 
Immature  infants,  care  of,  58 
Imperforate  anus,  150 

—  hymen,  625 

• —  rectum,   150 
Impetiginous  eczema,  781 
Impetigo  contagiosa,  787 
Implication  of  nerve  in  callus,  809. 
Inanition  fever,  3g 
Incontinence  of  urine,  614 
Incubators,  5g 

Indigestion,  diet  table  in,  11 1 
Infancy,  definition  of,  i 

—  dyspeptic  diseases  of,  83 

—  mortality  in,  14 
Infant,  weight  of,  10 
Infantile  chorea,  90 

—  convulsions,  532,  542 

—  hernia,  156 

—  intermittent  fever,  300,  319 

—  leucorrhoea,  241,  626 

—  osteomalacia,  203 

—  paralysis,  578,  736 

and  hip-disease,  697,  698 

—  scurvy,  192 
Infants,  diet  of,  39 

—  feeding  of,  39,  828 
Inflammatory  diarrhoea,  go 

Inflation  of  intestine  in  intussusception,. 

Influenza  epidemic,  2go 

—  bacillus  of,  2gi 


Index 


885 


Influenza,  pneumonia  in,  2gi 

—  relapses  in.  293 

—  scarlatinal  rash  in,  292 

—  tonsillitis  in,  292 

—  treatment  of,  293 

—  vomiting  in,  292 

Inguinal  adenitis,  692,  693,  699 

—  colotomy,    152 

—  hernia,  156 

Injections  in  intussusception,  138 
Injuries  of  soft  parts,  800 
Intermittent  fever,  infantile,  300,  319 

—  htemoglobinuria,  420,  594 
Interstitial  hepatitis,  188 
Intestinal  fistula,  124 

—  '  kinks,'  119 

—  obstruction,  acute,  131 

—  worms,  114 

Intestine,  congenital  obstruction  of,  148 
Intra-uterine  amputation.  744 

—  life,  I 

—  respiration,  3 
Intubation  of  larynx,  346,  830 
Intussusception,  131 

—  abdominal  section  in,  139 

—  of  appendix,  142 

—  chronic,  141 

—  inflation  in,  138 
Invagination  of  the  bowel,  131 
'  Inward  fits,'  533 

Irritable  mamma,  627 

—  rugous  bladder,  613 


Jaundice,  catarrhal,  183 
Jaundice  epidemic,  184 

—  obstruction  of  duct,  182 

—  of  infants,  26 

—  malignant,  184 

—  in  pneumonia,  370 
Jaw,  ankylosis  of,  685 

—  cysts  of,  776 

Joint  disease,  pyaemic,  668,  841 

—  sense,  691 

joints,  diseases  of  the,  660,  841 

—  haemorrhage  into,  441 
Jurymast,  721,  847 

Juxta  epiphysary  diaphysitis,  645 


Kidney,  granular.  606 

—  large  white,  606 

—  movable,  596 

—  tumours  of,  597 

Kidneys,  congenital  anomalies  of,  596 

—  diseases  of,  596 
Kinks  of  intestine,  iig 


Knee,  diseases  of,  661  et  scq.,  845 
Knock-knee,  212  et  seq.,  830 

—  from  muscular  spasm,  218 

—  rickets,  iw  et  seq. 
Kyphosis,  210,  227 


Labia,  hypertrophy  of,  625 

—  naevus  of,  625 

—  ulceration  of,  626 
Labyrinth,  affections  of,  762 
Laminectomy,  725,  848 
Landry's  paralysis,  577 
Laryngeal  diphtheria,  332,  830 
Laryngismus  stridulus,  323 
Laryngitis,  catarrhal,  329 

—  chronic.  343 

—  spasmodic,  327 

Larynx,  intubation  of,  346,  830 

—  papilloma  of,  349 
Latent  meningiis,  481 

Lateral  curvature  of  spine,  223,  385,  837 

treatment,  837 

from   caries,  717 

—  meningocele,  566 

—  sinus  thrombosis,  763 
Late  rickets,  216 

Leg,  fractures  of,  811,  841 
Leontiasis  ossea,  659 
Leucocythjemia,  439 
Leucorrhoea,  infantile,  241,  626 
Leukaemia,  439 
T^ichen  scrofulosus,  790 

—  strophulus,  62,  791 

—  urticatus,  790 
Lienteric  diarrhoea,  87 
Life,  intra-uterine,  i 
Limbs,  injuries  of,  801 

—  malformation  of,  743 

—  rickety,  deformities  of,   208   et  seq., 

835 
Lip,  cleft  of  lower,  174 
Lipoma.  770 
Lipomatous  nsevus,  428 
Lithaemia,   592 
Lithotomy,  611 
Lithotrity,   611 
Little's  tin  splint,  733 
Littre's  operation,  152 
Liver,  abscess  of,  190 

—  acute  yellow  atrophy  of,  184 

—  cirrhosis  of,  186 

—  diseases  of,  181 

—  enlargements  of,  iSi 

—  examination  of,  181 

—  fatty,  189 

—  hernia  of,  154 


886 


Index 


Liver,  hydatids  of,  190 

—  lymphadenoma  of,  191 

—  size  of,  181 

—  sypliilitic  affections  of,  187 

—  tuberculosis  of,  187,  189 

—  tumours  of,  191 
Lobar  pneumonia,  366 
Lobelia  in  whooping-cough,  317 
Local  ansesthesia,  818 
Lordosis,  210,  694 

Loss  of  blood,  814 
Ludvvig's  angina,  245 
Lumbar  colotomy,  152 
I.ungs,  abscess  of,  375 

—  caseation  of  the.  388 

— ■  chronic  tuberculosis  of,  390 
— ■  collapse  of,  353 

—  gangrene  of.  374 

—  syphilitic  affections  of,  453 

—  vital  capacity  of,  at  different  ages.  4 
Lupus,  383,  798 

—  hypertrophicus,  241 
Lymphadenoma,  775 

—  of  bronchial  glands,  390 

—  of  liver,  191 
Lymphangiomata,   cavernous,   428,   767 

—  cystic,  428,  767 
Lymphangitis,  reticular,  237 
Lymphatic  anaemia,  439 

—  glands,  distribution  of,  237 

—  naevus,  428,  767 

—  varix,  430 
Lymphoma,  775 
Lymphosarcoma,  775 


Macewen's  operation,  221,  837 
Macrocheilia,  175 
Macroglossia,  176,  427,  429,  767 
Macrostoma,  174 
Maculae,  pigmentary,  424 
Malarial  fever,  319 

Malformation  of  genito-urinary  organs, 
617 

—  of  limbs,.  743 

—  of  nose,  756 
.Malignant  jaundice,  184 
— ■  disease  of  stomach,  113 

—  polypi  of  nose,  757 
Malnutrition,  103 
Malunion  of  fractures,  812,  841 
Mamma,  irritable,  627 
Maniacal  chorea,  522 
Manipulation  for  club-foot,  848 
Mastoid  disease,  760  et  seq. 
Masturbation,  625 
Maternalimpressions,  166 


Measles,  266 

—  broncho  pneumonia  in,  270 

—  diagnosis  of,  271 

—  eruption  in,  269 

—  incubation  of,  268 
— -  laryngitis  in,  270 

—  mortality  in,  267 

—  glandular  enlargement  in,  271 

—  micro-organisms  in,  267 

—  morbid  anatomy  of,  271 

—  quarantine  in,  273 

—  treatment  of,  272 

—  tuberculosis  in,  271 
Meat  poisoning,  loi 

Meatus  urinarius,  contraction  of,  621 
Meckel's  diverticulum,  31,  155 
Meconium,  7 
Median  branchial  fistula,  179 

—  hare-lip,  174 
Mediastinal  abscess,  389 
Mediastino-pericarditis,  417 
Medulla,  tumours  of,  496 
Medullary  haemorrhage.  510 
Membrana  tympani,  rupture  of,  759 
Membranous  croup,  see  Diphtheria 

—  laryngitis,  332 

Meningeal  haemorrhage,  315,  502 

post  partum,  502 

Meningitis,  acute  simple,  477 

—  basal,  479 

—  cerebro-spinal,  480 

—  chronic,  482 

—  latent,  481 

—  in  pneumonia,  370 

—  purulent,  477,  481 

—  simple,  477 

—  spinal,  572 

—  syphilitic,  482,  485 

—  tubercular,  468 

—  vomiting  in,  470 
Meningocele,  570 
Meningo-myelocele,  566 

Mental  affections  in  childhood,  551 
— •  defect  affecting  speech,  549 

—  strain,  469,  516 
Mesenteric  disease,  144 
Metatarso-phalangeal  disease,  684 
Methods  of  operating  for  hare-lip,  170 
Microstoma.  175 

Middle  cerebral  artery,  thrombosis  of, 

511 

—  ear,  diseases  of,  475,  477,  498  et  seq., 

759 
Midge  bites,  797 
Miliaria,  791 

Miliary  tuberculosis,  acute,  232 
Milk,  condensed,  53 


Index 


887 


IMilk,  composition  of,  44 

—  cows,  44,  S52 

—  human,  composition  of,  46 

—  humanised,  48 

—  modified,  48.  828 

—  I'asieuri/.ation  of,  829 

—  ])eptonize<l,  52 

—  tuberculous  infection  from,  145 
Misplaced  testes,  627 

Mitral  regurgitation,  410  ct  scq. 

Mixed  ntevus,  422 

Mobile  spasm,  508 

Moles,  799 

Monsters,  745 

Morbus  coxro,  6S7 

Mortality  after  tracheotomy,  345 

—  in  infancy,  14 
Mother's  mark,  421 
Mouth,  absence  of,  177 

—  defects  of,  affecting  speech,  160,  549 

—  deformities  of,  165 

—  diseases  of,  64 

—  examination  of,  60 
Mucoid  cyst  of  tonsil,  74 
Mucous  cyst  of  pharynx,  78 

—  disease,  107 

—  parches,  452 
Mumps,  31S 

Muscle,  artificial,  733,  737,  -\o  et  seq. 
Muscles,  deficiencies  of,  743 

—  sclerosis  of,  591 
Muscular  atrophy,  5S6,  591 

—  spasm,  845. 
Myelitis,  575 
Myelocele,  566 
Myocarditis,  41  5 
Myositis  ossificans,  743 
Myotonie^  591 
Myxolipoma,  771 
Myxcedema,  559 


N.'Evus,  421 

—  congenital,  421  ' 

—  of  labia,  625 

—  lipomatodes,  428 

—  lymphatic,  428 

—  orbital,  427 

—  of  rectum,  163,  424 

—  of  tongue,  177,  427,  429 
Narcotics,  856 

Nasal  adenoid  vegetations,  77 
Nasal  catarrh,  754 

—  deformity,  756 

—  obstruction,  755 

—  polypi,  756 
Navel,  diseases  of,  31 


Navel-urachus  fistula,  31 
Necrosis,  acute,  637 

—  fracture  after,  645 

—  of  jaw,  67,  655 

—  of  patella,  655 

—  post-typhoid,  67 

—  of  rib — empyema,  643 

—  of  spinous  process,  713,  724 
Nephritis,  acute,  603 

—  chronic,  605 

—  in  dij^htheria,  284 

—  in  malarial  fever,  319 

—  in  pneumonia,  370 

—  in  scarlet  fever,  257 

—  parenchyma;:ous,  604 

—  septic,  258 

Nerve,  implication  of,  in  callus,  899. 
Nervous  system,  8 

diseases  of,  466 

Neuritis,  587 
Neuroma,  765 
Night  cry,  691 

—  starting,  6gi 

—  terrors,  545 

'  Nine-day  fits,'  35 
Nitrous  oxide  gas,  818 
Nodes,  241,  648,  649 
Nodules,  rheumatic,  460,  521 
Noma  pudendi,  627 
Nose,  diseases  of,  754 

—  dry  catarrh  of,  756 

—  malformation  of,  756 
Nystagmus,  539 


Oatmeal  water,  51 
Obliteration  of  bile-ducts,  182 
Obstetrical  paralysis,  25 
Obstruction  of  bowels,  acute,  131 

chronic,  142 

congenital,  148 

Obtui'ator  teats,  168 
Obturators.  174 
Occipito-atlantoid  disease,  713,  847 

—  dislocation,  751,  801 
OEdema  of  scrotum,  625 

—  neonatorum,  37 

CEsophageal  glands,  hypertrophy  of,  81 

—  varix,  81 
CEsophagitis,  81 
QLsophagotomy,  81 
(Esophagus,  stricture  of,  79,  180 

—  deformities  of,  79,  180 

—  foreign  bodies  in,  80 
Oidium  lactis,  66 
Omphalitis,  32 
Onychia,  797 


Index 


Onychia  maligna,  707 
Open  division  in  club-foot,  735,  848 
Operations 'under  anaesthetics,  816 
Ophthalmia,  gonorrhoeal,  37 
Optic  atrophy,  492  et  seq. 

—  neuritis,  233,  471,  492,  518 
Orbital  nsevus,  427 
Orchitis,  318,  628,  630,  631 
Osteoclasis,  220,  837 
Osteoma,  767 
Osteomalacia,  infantile,  203 

—  in  rickets,  203 
Osteomyelitis,  acute,  645 
circumscribed,  652 

—  chronic  circumscribed,  652 
— ■  —  diffuse,  654 

—  condensing,  637,  656 

—  pysemic,  657 

Osteophytic  growths  in  rickets,  214 
Osteotomy,  221,  837 

—  for  flexed  knee,  679 

—  of  ribs,  385 
Ostitis,  636 
Otitis  externa,  759 

—  in  measles,  271 

—  media,  475,  477,  498  et  seq.,  759 

—  scarlet  fever,  255  et  seq. 
Ovarian  hernia,  157,  631 

—  tumours,  635 

Overgrowth   of  limbs    from    periostitis, 

644 
Overlying,  536 
Oxyuris,  1 14 
Ozaena,  756 


Pachydermatocele,  429 
Pachymeningitis,  485 
Packs  in  scarlet  fever,  264 
Pain,  814 
Palate  arch,  shape  of,  174 

cleft  of,  165  et  seq 

Papilloma,  799 

—  of  branchial  fissures,  180 

—  of  larynx,  349 

—  of  tongue,  177 

—  of  uvula,  77 

Paracentesis  in  pericardial  effusion,  406, 

416 
Paralysis,  acute  atrophic,  578 
cerebral,  504 

—  after  diphtheria,  285 
—  infantile,  57S,   736 
Landry's,  577 

obstetrical,  25 

— •  pseudo-hypertrcphic,  588 
-Paralytic  chorea,  521 


Paralytic  club-foot,  736 
Paraphimosis,  624 
Paraplegia,  573 

—  ataxic,  577 

—  cervical,  720 

—  spastic,  501 

—  in  spina  bifida,  566  et  seq. 

—  in  spinal  caries,  573,  720,  725 
Parasitic  foetus,  772,  774 
Parenchymatous  nephritis,  604 
Parker's  operation  in  club-foot,  734 
Parosteal  abscess,  637 

Parotitis,  318 

Patella,  dislocation  of,  813 

in  knock-knee,  215,  216,  217 

—  necrosis  of,  655 
Patent  urachus,  31,  617 
Peliosis  rheumatica,  444 
Pelvic  abscess,  695 

—  deformity  in  rickets,  210,  216 
Pemphigus.  791 

—  syphilitic,  451 
Penis,  absence  of,  622 
Peri-articular  abscess,  667,  693 
Pericarditis,  402 

—  acute,  403 

—  chronic.  406 

—  diagnosis  of,  403 

—  symptoms  of,  403 

—  in  chorea,  516 

—  in  nephiitis,  260 

—  in  rheumatism,  459 

—  in  scarlet  fever,  257 
Pericardium  adherent,  412 
Periglandular  abscess,  240 
Perinephritic  abscess,  599 
Perioesophageal  abscess,  78,  80 
Periosteal  abscess,  637 
Periostitis,  637 

—  albuminosa,  652 

—  chronic,  648 

—  mixed  infection  in,  645 

—  exanthematous,  643,  649 

—  syphilitic,  649 
Peripheral  neuritis,  587 
Perisigmoid  abscess,  126,  127 
Peritoneal  abscess,  12C-127 

—  effusion,  chronic,  128 
Peritonitis,  acute,  118 

—  appendicular,  122 

—  chronic,  117,  128 

cicatrisation  from,  129 

—  in  enteric  fever,  298 

—  foetal,  149 

—  in  nephritis,  260 

—  purulent,  general,  120 

—  tuberculous,  chronic,  128 


Index 


889 


I'erityphlitic  abscess,  122-124,  127 

Perityphlitis,  122-124,  127 

Pernicious  ancemia,  434 

Pes  cavus,  729,  735 

in  genu  valgum,  215,  216 

—  gigas,  429,  771 

—  planus.  73S,  849 

—  pronatus  acquisitus,  73S 
'  Petit  mal,'  527 
Pharyngeal  tonsil,  77 
Pharyngitis,  77 
Pharynx,  abscess  of,  78 

—  mucous  cyst  of,  78 
Phimosis,  622 
Phlebitis,  umbilical,  34 

—  lateral  sinus,  763 
Phlegmonous  periostitis,  37 
Phthisis,  acute,  393 

—  fibroid,  393 
Pigeon-breast,  201,  202 
Pigmentary  maculae,  424 
Piles,  163 

Pinna,  diseases  of,  758 

—  malformations  of,  178 
Plaster-of- Paris  jackets,  721 
Pleurisy,  375 

—  in  rheumatism.  459 
Pleuropneumonia,  370 

—  in  rheumatism,  459 
Pneumonia,  abortive,  369 

—  cerebral,  370 

—  creeping,  370 

—  croupous,  366 
pathology  of,  372 

—  gastric,  370 

—  jaundice  in,  370 

—  in  nephritis,  370 

—  relapsing,  370 

—  secondary,  357 
Polypi,  nasal.  756 
Polypus  recti,  163 

—  umbilical,  31 
Polyuria,  464 

Pons,  tumours  of,  496 

Poroplasiic  jackets,  723,  840 

Port- wine  stain,  421 

Post-hemiplegic  epilepsy,  529 

Post-nasal  adenoids,  77 

Post-partum  meningeal  haemorrhage,  502 

Post-pharyngeal  abscess,  78 

Pott's  disease,  713,  S47 

paraplegia  in,  573,  720,  725,  847 

Praevertebral  abscess,  78,  724 
Primary  amputations,  812 

—  resections,  812 

—  union  after  excision  of  hip,  708,  712 
Prolapse  of  rectum,  160 


Prolapse,  of  urethra,  622 
Prostate,  enlarged,  621 
Pseudo-diphtheria,  332 
Pseudo-hypertrophic  paralysis,  588 
Pseudo-paralysis,  syphilitic,  454,  650 
Psoas  abscess,  697,  698,  715,  724 
Psoitis,  127 
Psoriasis,  791 

Psychical  phenomena  of  infants,  10 
Pulpy  disease  of  joints,  618  et  seq. 
Pulse  at  birth,  5 
Pulsus  paradoxus,  419 
Purgatives,  858 
Purpura,  442 

—  hsemorrhagica,  442 

—  simplex,  442 

Purulent  peritonitis,  120-127 
Pya?mia,  638.  657  et  scq. 

—  osteomyelitis  in,  657 

—  in  periostitis,  638  et  seq.,  643 
Pyaemic  joint-disease,  668 
Pyelitis,  602 

Pylorus,  stenosis  of,  112 
Pyuria,  594 


'  Quiet  strumous  disease,'  663 
Quinine  in  pneumonia,  373 


Radical  cure  of  hernia,  159 

Radius,  subluxation  of,  812 

Ranula,  176 

Rarefying  ostitis,  636 

Raynaud's  disease,  420 

Reaction  of  degeneration,  581 

Reclining  board,  226 

Rectal  abscess  in  sacral  disease,  726 

—  adenoma,  163 

—  dermoid  cysts,  164 

—  fistula,  163 

—  hernia,  161 

—  nffivus,  163,  424 

—  polypus,  163 

—  prolapse,  161 

—  stricture,  164 

—  ulcers,  164 

Rectangular  talipes  equinus,  729 

Rectum,  imperforate,  152 

Recurved  knee,  749,  850 

Red  corpuscles  at  birth,  5 

'  Redressement  force  '  in  rickets,  220 

Reflex  vomiting,  85 

Relapse  after  excision  of  tonsils,  76 

Relapsed  club-foot,  733,  738 

—  necrosis,  645 

Removal  of  sequestra  from  spine,  725 


890 


hide: 


Removal  of  inflamed  tonsils,  76 
Renal  calculus,  602 

—  new  growths,  597 

Resection  of  bone  in  periostitis,  640 
Resections,  primary,  S12 
Residual  abscess,  701,  706 
Respiration  in  newly  born,  3 

—  intra-uterine,  3 

—  system,  diseases  of,  321 
Retention  of  urine,  616,  801 
Reticular  lymphangitis,  237 
Retro-oesophageal  abscess,  78,  80 
Retro-peritoneal  glands,  diseases  of ,  444 
Retro-pharyngeal  abscess,  78,  80 
Rheumatic  arthritis,  461,  669 

—  nodules,  460 

—  pericarditis,  459 
Rheumatism,  458,  519 

—  chronic,  461 

—  gonorrhoeal,  670 
Rhinitis  fibrinosa,  283 
Ribs,  resection  of,  385 
Rickets,  197 

—  acute,  200 

—  of  adolescence,  216 

—  in  animals,  198 

—  bone  changes  in,  204 

—  causes  of,  198 

—  congenital,  203 

—  deformities  of,  208,  835 

treatment  01,  218,  836 

—  foetal,  203 

—  genu  valgum  from,  21 1,  837 

—  scurvy  in,  192 

—  syphilis  and,  108 

—  vi.sceral  change  in,  206 

—  late,  216 

Rickety  pelvis,  210,  216 

—  spine,  210,  836 

Rigidity  of  joints,  congenital,  749 
Ringworm,  794 
Rizzoli's  operation,  154,  837 
Roseola,  lateral,  788 
Rotatocurvatureof  spine,  233,  385,  717, 

837 
Rotheln,  273 
Rubella,  273 

—  complications  of,  276 

—  diagnosis  of,  277 

—  incubation  in,  274 

—  morbillosa,  275 

—  quarantine  in,  277 

—  rash  of,  275 

—  scarlatinosa,  275 

—  treatment  of,  277 
Rugous  bladder,  613 
Rupture,  inguinal,  156 


Rupture,  umbilical,  155 
—  of  urethra,  801 


Sacculi  in  lower  lip,  174 
Sacral  tumours,  congenital,  772 

—  dimple,  569 

—  disease,  726 
Sacro-iliac  disease,  684 
Saliva,  secretion  of,  6 

—  composition  of,  6 
Salivation  in  children,  457 
Sarcoma,  764 

—  of  kidney,  597 
Sayre's  jacket,  721,  847 

'  Scabbard  trachea,'  778 
Scabies,  796 
Scalds,  813 

—  of  glottis,  345 
Scapula,  deficiency  of,  732 
Scarification  of  glottis,  345 
Scarlet  fever,  249 

complications  of,  255 

— •  —  diagnosis  of,  260 

enlarged  glands  in,  256 

incubation  of,  251 

•  malignant,  254 

micrococci  in,  262 

mild  form  of,  253 

morbid  anatomy  of,  261 

mortality  of,  250 

nephritis  in,  258 

otitis  in,  255 

peritonitis  in,  260 

pneumonia  in,  256,  260 

prognosis  in,  255 

pysemia  in,  257 

quarantine  in,  266 

synovitis  in,  256 

septicaemia  in,  257 

surgical,  250 

symptoms  of,  251 

treatment  of,  262 

Scars,  depressed,  243 
School-made  chorea,  516 
Sclerema  neonatorum,  36 
Sclerosis  of  bone,  637,  656 

—  of  brain,  488 
— -  of  muscle,  59T 
Scissor-legged  deformity,  712 
Scoliosis,  225,  385,  717,  837 
Scorbutus,  192,  435 
Scrofula,  types  of,  236 
Scrofuloderma,  241 
Scrofulous  gumma,  241 

—  neck.  239,  240 
Scrotum,  oedema  of,  625 


Index 


891 


Scurvy,  435 

—  infantile,  iq2 
Seborrhoea,  "87 
Separation  of  the  cord,  31 

—  of  epiphyses,  803 
Septicaemia  in  scarlet  fever,  257 
Septic  diseases,  815 

—  nephritis,  25S 

Septum  nasi,  deviation  of,  755 
Septum  ventriculorum,  open,  400 
Serous  cysts,  430,  767 

—  synovitis,  660,  667 
Shock,  S14 

Shoulder,  dislocations  of,  751,  S12 

—  growing  out  of,  224 

—  tuberculous  disease  of,  664,  843 
Sight  in  infants,  g 

Sinus,  cavernous,  thrombosis  of,  763 

—  cervicalis,  179 

—  lateral,  763 

—  umbilical,  124 
Siren  foetus,  567 

Skin  affections  in  syphilis,  451 

—  diseases  of.  7S0 
Skull,  cubic  capacity  of,  8 

—  ("raclure  of,  800,  Soi 
Sleep,  10 

Softening  of  brain,  476,  514 
Spasm  of  <jiottis,  323,  328 
Spasmodic  laryngitis,  327 

—  torticollis,  742,  850 
Spastic  paraplegia,  501 
Speech,  anomalies  of,  546 
Spina  bifida,  566 

and  hydrocephalus,  569 

occulta,  566 

Spinal  abscess,  715,  717 

—  caries.  713' 

paralysis  in,  573,  720,  725 

—  deformity,  angular,  713 
dyspnoea  from,  329 

—  meningitis,  572 

—  meningocele,  566 

—  rigidity,  718 

—  sequestra,  removal  of,  725 

—  splints,  721,  S47 

—  supports.  426,  720,  847 
Spine,  forcible  straightening,  224 

—  lateral  curvature  of,  223,  3S5,  717,  837 

—  operations  on,  724,  825 

—  periostitis  of,  643 

—  rickety,  210,  835 

—  rotato-lateral  curvature  of,  223,  385, 
717.  837 

—  vireak,  224 

Spinous  process,  necrosis  of,  713,  724 
Spleen,  enlargement  of,  436,  453 


Spleen,  syphilitic  affection  of,  453 
Splenic  antemia,  436 

—  enlargement  in  malaria,  319 
Sporadic  cretinism,  559 
Spurious  talipes  valgus,  738,  849 
Stammering,  550 

Staphyloraphy,   172  • 

Status  epilepticus,  529 

Steam  tent,  330 
Stellate  na-vus,  421,  424 
Stenosis  of  the  aorta,  401 

—  of  mitral  valves,  401 

—  of  pulmonary  artery,  400 

—  of  pylorus,  1 12 
Sterilisation  of  milk.  52 
Sternoclavicular  joint,  disease  of,  685 
Sterno-mastoid,  hematoma  of,  24,  740 

—  tumour,  24,  740 
Sternum,  fissure  of,  752' 
Stimulants,  860 

Stomach,  capacity  of,   in  infancy,  6 

—  of  infancy,  6 

—  carcinoma  of,  113 

—  dilatation  of,  112 

—  malformations  of,  113 

—  ulcer  of,  114 
.Stomatitis,  catarrhal,  64 

—  gangrenous,  6g 

—  hgemorrhagic,  67 

—  herpetic,  65 

—  membranous,  65 

—  parasitic,  64 

—  ulcerative,  67 

Stone  in  the  bladder,  609 
Strangulated  hernia,  157 
Stricture  of  sesophagus,  79 

—  of  rectum,  164 

—  of  urethra,  621,  801 
Strophulus,  62,  791 
Strumous  dactylitis,  657 

—  nodes,  241 

—  periosteal  nodes,  648 
Subcutaneous  nasvus,  422 
Subjective  symptoms  of  spinal  disease, 

718 
Sublingual  cysts,  176 
Subperiosteal  abscess,  637 
Sudamina,  791 

Sudden  death  in  nephritis,  260 
Sunstroke,  247 
Supernumerary  auricles,  178 

—  digits,  746 

—  testes,  631 

Suppuration  of  bronchial  glands,  387 
Suprapubic  lithotomy,  611 
Suprascapula,  development  of,  752 
Surgical  scarlet  fever,.  815 


892 


Index 


Surgical  treatment  of  empyema,  382 

—  tuberculosis,  243 
Swallowing  foreign  bodies,  80 
Syndactylism,  744 
Syndesmotomy,  734 
Synovitis    acute  tuberculous.  672 

—  of  adolescents,  710 

—  catarrhal,  668 

—  exanthematous,  256,  660,  668 

—  serous,  667 

—  suppurative,  f.67 

—  syphilitic,  66g 

—  tuberculous,  672 
Syphilis,  446 

—  acquired,  446 

—  arteritis.  454 

—  brain  affection  in,  454,  482 

—  congenital,  447 

—  cranio-tabes  in,  450 

—  eye  affections  in,  454 
■ —  hepatitis  in,  187,  453 

—  hereditary,  447 

—  lung  affections  in,  453 

—  malnutrition  in.  450 

—  post-vaccinal,  447 

—  skin  affections  in,  451 

—  visceral  lesions  in,  453 
Syphilitic  coryza,  452,  453 

—  dactylitis,  657 

—  epiphysitis,  454,  650 
Syphilitic  hip-disease,  697,  698 

—  idiocy,  454,  557 

—  meningitis,  482,  485 

—  ostitis,  454  et  seq. 

—  pem.phigus,  451 

—  pseudo-paralysis,  454,  650 

—  spleen,  453 

—  teeth,  454 

—  telostitis,  454,  650 

—  testitis,  632 
Syringo-myelocele,  566 


T^NIA  mediocanellata,  116 

—  solium,  116 
Talipes,  acquired,  727 

—  calcaneus,  729,  73S 

—  cavus,  729 

—  equino-varus,  569    727,  84S 

—  paralytic,  736,  848 

—  valgus,  728,  848 

—  varus,  727 
Tape- worm,  116 
Tarsectomy,  682 

—  for  clubfoot,  735 
Taste  in  infants,  10 
Teeth,  eruption  of,  12 


Teeth,  syphilitic,  454 
Telangiectasis,  421 
Telostitis,  454,  650 
Temperature  in  health,  8 

—  at  birth,  8 
Tenosynovitis,  743 

Tenotomy  for  club-foot,  734  et  seq.,  8. 
Tent,  steam,  for  laryngitis,  330 
Testis,  abnormalities  of,  627 

—  diseases  of,  631 

—  inflammation  of,  631 

—  syphilitic,  632 

—  torsion  of,  632 

—  tubercle  of,  632 

—  tumours,  633 

—  undescended,  267 
Tetanus  nascentium,  35 
Tetany,  537 

Thigh,  fractures  of,  811 

Thomas's  splints,  673,  705,  722,  S47 

Thomsen's  disease,  591 

Thorax  in  infancy,  321 

Thread-worms,  114 

Thrombosis  of  cerebral  sinuses,  514 

Thrush,  65 

Thumb-sucking,  deformity  from,  177 

Thymus,  778 

Thyroid,  diseases  of,  777 

—  duct  cysts,  179,  180 
Thyro-glossal  duct,  179 
Thyrotomy,  349 

Tibia,  deformities  of,  213  et  seq. 
Tinea  circinata,  794 

—  tonsurans,  793 

Toes,  diseases  of,  684,  771 
Tongue,  absence  of,  175 

—  condyloma  of,  177 

—  malformations  of,  175 

—  nsevus  of,  177,  427,  429 

—  papilloma  of,  177 

—  swallowing,  176 

—  tumours  of,  177 
Tongue-tie,  175 
Tonsil,  cyst  of,  74 

—  enucleation  of,  76 

—  guillotine,  76 

—  pharyngeal,  77 

Tonsils,  removal  of  inflamed,  76 
Tonsillar  calculus,  76 

—  hypertrophy,  74 
Tonsillitis,  acute,  70 

—  chronic,  74 
Torsion  of  testis,  632 
Torticollis,  24,  741,  850 
Trnchea,  aspirator  for,  340 

—  compression  of,  328 

—  ulceration  of,  343,  344,  34S 


Index 


893 


Tracheal  dilator,  340 

—  fistula,   180 

—  stenosis,  344 
Traclieotomy,  336 

—  tubes,  3^2 

Traction  diverticula  of  gullet,  79 
•  Translucent  hernia,  i£7 
Transpatellar  excision,  677 
Transposition  of  aorta,  402  ^ 
Transverse  myelitis,  575 
Traumatic  stricture  of  urethra,  801 
Travelling  acetabulum,  6S9 
Trephininii;  skull,  499,  762,  763 

—  for  epilepsy,  531 

—  spine,  725 
Trismus  neonatorum,  35 
Trochanter,  disease  of,  698 
Trophic  ulcers,  567,  570 
Trusses,  158 

Tubercles  of  choroid,  233 
Tuberculosis  of  adrenals,  607 

—  acute  miliary,  232 

—  chronic,  of  lung,  390 

—  congenital,  228 

—  general,  234 

sub-acute,  234 

surgical,  243,  841 

—  of  liver,  187,  189 

—  broncho-pneumonia,  form  of,  232 

—  primary  infection,  841 
Tuberculosis  and  scrofula,  236 

—  typhoid  form  of,  232 
Tuberculous  abscess  of  kidney,  600 

—  adenitis,  237 

—  cystitis,  613 

—  dactylitis,  657 

—  disease^of  ankle,  666 
of  elbow,  664,  843 

—  embolism,  229,  237 

—  infection  from  milk,  145 

—  kidney,  600 

—  meningitis,  468 

anatomy  of,  475 

symptoms  of,  469 

treatment  of,  476 

—  peritonitis,  chronic,  128 

—  shoulder,  664,  843 

—  synovitis,  660  ei  seq. 
acute,  672 

—  testis,  632 

—  ulceration  of  bowel,  144 

—  ulcers,  241 

—  wrist,  664,  843 

Tubes  for  tracheotomy,  342 
Tumour  growth.  764 
Tumours  of  basal  ganglia,  496 

—  of  bladder,  613 


Tumours  of  brain,  491 

—  (jf  cerebellum,  493 

—  cerebral,  491 
removal  of,  499 

—  congenital,  764  cl  seq. 

—  of  frontal  lobe,  497 

—  of  kidneys,  597 

—  of  liver,  191 

—  of  ovary,  635 

—  of  pons,  496 

—  of  testis,  633 
Types  of  scrofula,  236 
Typhlo-peritonitis,  122 
Typhoid  form  of  tuberculosis,  232 

—  fever,  293 

—  periostitis,  643,  649 

—  synovitis,  668 
Typhus,  303 

—  diagnosis  of,  305 

—  mortality  in,  303 

—  rash  in,  304 

—  symptoms  of,  303 

—  treatment  of,  305 


Ulceration  of  bone,  tubercular,  636 

—  of  labia,  241,  626 

—  -  of  navel,  32 

—  of  nose,  756 

—  of  trachea,  343,  348 
Ulcerative  endocarditis,  336 

—  stomatitis,  62 
Ulcers  of  the  anus,  155 

—  of  the  rectum,  155 

—  of  the  stomach,  114 

—  trophic.  567,  570 

—  tuberculous,  241 

—  vulvar,  241,  626 
Umbilical  arteritis,  33 

—  fistula,  124 

—  haemorrhage,  34 

—  hernia,  155 

—  phlebitis,  34 

—  polypus,  31 

—  sinus,  124 

Umbilicus,  deformities  of,  154 

—  diseases  of,  31 

—  gangrene  of.  32 

—  ulceration  of,  32 
Undescended  testes,  627 

Union  of  epiphyses,  dates  of,  810 
Ununited  fractures,  645,  S02,  S41 

from  necrosis,  645 

Uraemia  in  scarlatinal  nephritis,  259 
Urachus,  patent,  31,  617 
Uranoplasty,  173 
Urethra,  obliteration  of,  621 


894 


Index 


Urethra,  double,  622 

—  prolapse  of,  622 

—  rupture  of,  801 

—  stricture  of,  621 

Urinary  meatus,  tumour  of,  622 

—  organs,  diseases  of,  592 
Urine,  composition  of,  7 

—  extravasation  of,  610,  617,  80 

—  incontinence  of,  614 

—  retention  of,  616 
Urticaria,  790 

Uvula,  enlargement  of,  77 

—  ncevus  of,  427 

—  papilloma  of,  77 


Vaccination,  erythema  after,  310 

—  erysipelas  after,  310 

—  glandular  enlargement  after,  310 

—  performance  of,  309 

—  rashes  after,  310 
Vaccino-syphilis,  310,  447 

Vaginal  discharge,  due  to  worms,  114 

—  haemorrhage,  30 
Vaginitis,  625 

Vapour  baths,  in  nephritis,  265 
Varicella,  305 

—  contagious  nature  of,  306 

—  diagnosis  of,  308 

—  eruption  in,  307 

—  gangraenosa,  307 
— •  incubation  of,  307 

—  quarantine  in,  308 

—  treatment  of,  309 
Varicocele,  635 
Varioloid,  311 

—  diagnosis  of,  312 

—  treatment  of,  312 

Varix,  arteriovenous,  427,  428 

—  lymphatic,  430 

—  of  oesophagus,  81 
Veal  tea,  853 
Venous  naevus,  421 
Ventral  hernia,  155 
Vertebral  osteomyelitis,  643 
Vesical  calculus,  609 
Vicarious  emphysema,  360 
Visceral  nsevus,  424 

Vital  capacity  of  lungs,  4 
Vomiting,  chronic,  105 

—  in  cerebral  tumour,  492 


Vomiting  in  chloroform  anaesthesia,  823 

—  in  gastric  catarrh,  84 

—  in  hysteria,  85,  542 

—  in  infants,  84 

—  in  meningitis,  470 

—  in  obstruction  of  the  bowels,  133 

—  in  peritonitis,  119 

—  in  scarlet  fever,  251 

—  in  whooping-cough,  314 
Vulvar  anus,  150 

—  ulcers,  241,  626 
Vulvitis,  625 


Warts  of  vulva,  627 
Water  on  the  brain,  94,  474 
Weak  spine,  224 
Weaning,  42 
Web-fingers,  748 

—  toes,  699 

Weight  and  height,  864 

—  chart,  II 

—  increase  of,  11 
W^et  nurses,  41 
Whey,  50 

'  White  lock-jaw,'  36 
Whooping-cough,  312 

—  broncho-pneumonia  in,  315 

—  contagiousness  of,  313 

—  convulsions  in,  315 

—  diagnosis  of,  315 

—  diarrhoea  in,  315 

—  emphysema  in,  315 

—  incubation  of,  313 

—  pathology  of,  316 

—  treatment  of,  316 

—  tuberculosis  after,  315 
Winckel's  disease,  29 
Worms,  intestinal,  114 

—  round,  I15 

—  tape,  116 

—  thread,  114 

Wound  management,  815 
Wrist  joint,  disease  of,  664,  843 
Wryneck,  741,  850 

Youth,  2 

Zymotic  diarrhoea,  90 

—  diseases,  246 


ifi! 


NEWYORK 


^  ^  /^  ^  ^ 


'i^ 


*^v 


•v. 


f?!i^is^ 


